- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,141.39 / $3,808.32
| Facility | | $1,277.00 | $2,141.39 | $3,808.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.23 / $2,141.39 / $2,548.25
| Professional | | $1,667.23 | $2,141.39 | $2,548.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.37 / $2,280.92 / $2,280.92
| Professional | | $1,723.37 | $2,280.92 | $2,280.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.83 / $3,121.20 / $4,395.00
| Professional | | $2,123.83 | $3,121.20 | $4,395.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,230.00 / $2,421.00
| Facility | | $375.00 | $1,230.00 | $2,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.86 / $2,302.08 / $3,582.93
| Professional | | $1,500.86 | $2,302.08 | $3,582.93 |