- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,459.61 / $4,637.72
| Facility | | $1,277.00 | $2,459.61 | $4,637.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.01 / $2,587.09 / $3,321.69
| Professional | | $1,975.01 | $2,587.09 | $3,321.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,354.46 / $2,943.09 / $3,116.21
| Professional | | $2,354.46 | $2,943.09 | $3,116.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,285.23 / $3,180.02 / $4,477.54
| Professional | | $2,285.23 | $3,180.02 | $4,477.54 |
- 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
- $1,847.20 / $2,430.48 / $4,193.49
| Professional | | $1,847.20 | $2,430.48 | $4,193.49 |