- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,542.92 / $5,399.03
| Facility | | $1,277.00 | $2,542.92 | $5,399.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,216.44 / $3,024.36 / $3,713.51
| Professional | | $2,216.44 | $3,024.36 | $3,713.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,604.63 / $4,770.84 / $4,770.84
| Professional | | $3,604.63 | $4,770.84 | $4,770.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,025.00 / $4,379.64 / $5,504.35
| Professional | | $3,025.00 | $4,379.64 | $5,504.35 |
- 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
- $2,053.89 / $2,737.00 / $4,948.21
| Professional | | $2,053.89 | $2,737.00 | $4,948.21 |