- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,967.33 / $5,550.85
| Facility | | $1,277.00 | $2,967.33 | $5,550.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,367.28 / $3,106.47 / $3,734.59
| Professional | | $2,367.28 | $3,106.47 | $3,734.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,816.25 / $3,520.31 / $3,727.39
| Professional | | $2,816.25 | $3,520.31 | $3,727.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,778.63 / $3,857.53 / $5,402.95
| Professional | | $2,778.63 | $3,857.53 | $5,402.95 |
- 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
- $2,320.65 / $3,049.11 / $5,038.88
| Professional | | $2,320.65 | $3,049.11 | $5,038.88 |