- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,427.51 / $9,034.00
| Facility | | $1,277.00 | $2,427.51 | $9,034.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.20 / $2,427.51 / $2,921.07
| Professional | | $1,787.20 | $2,427.51 | $2,921.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,141.23 / $2,676.54 / $2,833.98
| Professional | | $2,141.23 | $2,676.54 | $2,833.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,207.67 / $3,062.92 / $3,756.03
| Professional | | $2,207.67 | $3,062.92 | $3,756.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $3,356.00 / $6,957.00
| Facility | | $1,565.00 | $3,356.00 | $6,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,799.30 / $2,368.80 / $3,813.33
| Professional | | $1,799.30 | $2,368.80 | $3,813.33 |