- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,677.68 / $5,109.38
| Facility | | $1,277.00 | $2,677.68 | $5,109.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,151.23 / $2,856.54 / $3,432.23
| Professional | | $2,151.23 | $2,856.54 | $3,432.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,592.89 / $3,241.12 / $3,431.77
| Professional | | $2,592.89 | $3,241.12 | $3,431.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.15 / $3,545.00 / $4,822.04
| Professional | | $2,510.15 | $3,545.00 | $4,822.04 |
- 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
- $2,071.71 / $2,762.22 / $4,823.89
| Professional | | $2,071.71 | $2,762.22 | $4,823.89 |