- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,556.33 / $5,309.48
| Facility | | $1,277.00 | $2,556.33 | $5,309.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,236.03 / $2,850.70 / $3,702.59
| Professional | | $2,236.03 | $2,850.70 | $3,702.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,603.52 / $4,769.37 / $4,769.37
| Professional | | $3,603.52 | $4,769.37 | $4,769.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,599.31 / $4,129.62 / $5,436.87
| Professional | | $2,599.31 | $4,129.62 | $5,436.87 |
- 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
- $2,001.69 / $2,647.78 / $4,778.55
| Professional | | $2,001.69 | $2,647.78 | $4,778.55 |