- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,597.17 / $4,915.70
| Facility | | $1,277.00 | $2,597.17 | $4,915.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,096.57 / $2,749.32 / $3,511.51
| Professional | | $2,096.57 | $2,749.32 | $3,511.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,494.83 / $3,118.54 / $3,301.98
| Professional | | $2,494.83 | $3,118.54 | $3,301.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,280.09 / $3,376.33 / $4,759.58
| Professional | | $2,280.09 | $3,376.33 | $4,759.58 |
- 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
- $1,988.36 / $2,715.37 / $4,496.89
| Professional | | $1,988.36 | $2,715.37 | $4,496.89 |