- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,422.16 / $4,419.27
| Facility | | $1,277.00 | $2,422.16 | $4,419.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,883.24 / $2,467.12 / $2,967.35
| Professional | | $1,883.24 | $2,467.12 | $2,967.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.84 / $2,804.80 / $2,969.79
| Professional | | $2,243.84 | $2,804.80 | $2,969.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,183.34 / $3,069.05 / $4,286.85
| Professional | | $2,183.34 | $3,069.05 | $4,286.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $900.00 / $2,421.00
| Facility | | $375.00 | $900.00 | $2,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,840.88 / $2,382.31 / $3,998.40
| Professional | | $1,840.88 | $2,382.31 | $3,998.40 |