- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.42 / $1,277.42 / $3,284.78
| Facility | | $1,277.42 | $1,277.42 | $3,284.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.00 / $1,715.39 / $2,737.32
| Professional | | $1,075.00 | $1,715.39 | $2,737.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,097.21 / $2,097.21 / $3,078.81
| Professional | | $2,097.21 | $2,097.21 | $3,078.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,094.93 / $1,423.41 / $3,284.78
| Facility | | $1,094.93 | $1,423.41 | $3,284.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.93 / $2,646.08 / $3,649.76
| Professional | | $1,094.93 | $2,646.08 | $3,649.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.45 / $2,189.86 / $3,129.08
| Professional | | $766.45 | $2,189.86 | $3,129.08 |