- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,193.23 / $3,880.40
| Facility | | $1,277.00 | $2,193.23 | $3,880.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,709.54 / $2,193.23 / $2,466.94
| Professional | | $1,709.54 | $2,193.23 | $2,466.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.32 / $2,323.21 / $2,323.21
| Professional | | $1,755.32 | $2,323.21 | $2,323.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,157.26 / $2,999.26 / $4,000.00
| Professional | | $2,157.26 | $2,999.26 | $4,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,056.00 / $2,558.00
| Facility | | $375.00 | $1,056.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,688.29 / $2,367.84 / $3,668.27
| Professional | | $1,688.29 | $2,367.84 | $3,668.27 |