- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,233.00 / $2,477.00 / $3,123.22
| Facility | | $1,233.00 | $2,477.00 | $3,123.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.03 / $2,535.64 / $3,123.22
| Professional | | $1,875.03 | $2,535.64 | $3,123.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,181.87 / $2,727.34 / $2,887.77
| Professional | | $2,181.87 | $2,727.34 | $2,887.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,788.49 / $3,120.53 / $3,834.17
| Professional | | $1,788.49 | $3,120.53 | $3,834.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,104.00 / $4,334.00 / $8,676.00
| Facility | | $2,104.00 | $4,334.00 | $8,676.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,911.14 / $2,555.36 / $4,220.55
| Professional | | $1,911.14 | $2,555.36 | $4,220.55 |