- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,371.06 / $4,557.13
| Facility | | $1,277.00 | $2,371.06 | $4,557.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,078.54 / $2,543.81 / $3,131.40
| Professional | | $2,078.54 | $2,543.81 | $3,131.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,042.82 / $4,027.26 / $4,027.26
| Professional | | $3,042.82 | $4,027.26 | $4,027.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,639.14 / $3,696.48 / $4,643.04
| Professional | | $2,639.14 | $3,696.48 | $4,643.04 |
- 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
- $1,748.43 / $2,331.23 / $4,173.95
| Professional | | $1,748.43 | $2,331.23 | $4,173.95 |