- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,117.86 / $3,952.18
| Facility | | $1,277.00 | $2,117.86 | $3,952.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.97 / $2,094.19 / $2,599.64
| Professional | | $1,653.97 | $2,094.19 | $2,599.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,007.77 / $2,509.71 / $2,657.34
| Professional | | $2,007.77 | $2,509.71 | $2,657.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.25 / $2,696.15 / $3,623.66
| Professional | | $1,860.25 | $2,696.15 | $3,623.66 |
- 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
- $1,595.35 / $2,110.37 / $3,541.53
| Professional | | $1,595.35 | $2,110.37 | $3,541.53 |