- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,747.25 / $5,112.85
| Facility | | $1,277.00 | $2,747.25 | $5,112.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,178.85 / $2,858.41 / $3,511.05
| Professional | | $2,178.85 | $2,858.41 | $3,511.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,414.17 / $4,518.76 / $4,518.76
| Professional | | $3,414.17 | $4,518.76 | $4,518.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,155.44 / $4,136.47 / $5,198.80
| Professional | | $3,155.44 | $4,136.47 | $5,198.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,056.00 / $2,558.00
| Facility | | $375.00 | $1,056.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,066.46 / $2,742.72 / $4,673.55
| Professional | | $2,066.46 | $2,742.72 | $4,673.55 |