- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,789.40 / $5,310.32
| Facility | | $1,277.00 | $2,789.40 | $5,310.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.69 / $2,970.65 / $3,535.07
| Professional | | $2,264.69 | $2,970.65 | $3,535.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,695.38 / $3,369.23 / $3,567.42
| Professional | | $2,695.38 | $3,369.23 | $3,567.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,618.14 / $3,637.92 / $5,032.28
| Professional | | $2,618.14 | $3,637.92 | $5,032.28 |
- 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
- $2,114.27 / $2,863.78 / $4,816.78
| Professional | | $2,114.27 | $2,863.78 | $4,816.78 |