- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,956.02 / $5,363.02
| Facility | | $1,277.00 | $2,956.02 | $5,363.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,163.59 / $2,956.02 / $3,671.61
| Professional | | $2,163.59 | $2,956.02 | $3,671.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,598.39 / $4,762.58 / $4,762.58
| Professional | | $3,598.39 | $4,762.58 | $4,762.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,298.00 / $4,302.42 / $5,493.10
| Professional | | $3,298.00 | $4,302.42 | $5,493.10 |
- 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
- $2,200.67 / $2,928.48 / $4,958.27
| Professional | | $2,200.67 | $2,928.48 | $4,958.27 |