- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $3,062.63 / $6,010.47
| Facility | | $1,277.00 | $3,062.63 | $6,010.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,670.09 / $3,354.22 / $4,174.47
| Professional | | $2,670.09 | $3,354.22 | $4,174.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,048.03 / $5,357.69 / $5,357.69
| Professional | | $4,048.03 | $5,357.69 | $5,357.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,338.47 / $4,843.72 / $6,156.24
| Professional | | $3,338.47 | $4,843.72 | $6,156.24 |
- 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
- $2,348.01 / $3,242.17 / $5,534.25
| Professional | | $2,348.01 | $3,242.17 | $5,534.25 |