- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,604.21 / $5,220.00
| Facility | | $1,277.00 | $2,604.21 | $5,220.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,195.44 / $2,823.54 / $3,473.50
| Professional | | $2,195.44 | $2,823.54 | $3,473.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,649.14 / $3,311.42 / $3,506.21
| Professional | | $2,649.14 | $3,311.42 | $3,506.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,535.69 / $3,511.17 / $4,846.91
| Professional | | $2,535.69 | $3,511.17 | $4,846.91 |
- 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
- $2,103.41 / $2,815.58 / $4,774.59
| Professional | | $2,103.41 | $2,815.58 | $4,774.59 |