- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,933.87 / $5,419.95
| Facility | | $1,277.00 | $2,933.87 | $5,419.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,335.40 / $3,042.15 / $3,723.71
| Professional | | $2,335.40 | $3,042.15 | $3,723.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,619.65 / $4,790.72 / $4,790.72
| Professional | | $3,619.65 | $4,790.72 | $4,790.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,285.85 / $4,462.93 / $5,526.63
| Professional | | $3,285.85 | $4,462.93 | $5,526.63 |
- 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
- $2,196.78 / $2,970.24 / $5,117.91
| Professional | | $2,196.78 | $2,970.24 | $5,117.91 |