- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,214.53 / $3,951.05
| Facility | | $1,277.00 | $2,214.53 | $3,951.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.07 / $2,214.53 / $3,948.00
| Professional | | $1,723.07 | $2,214.53 | $3,948.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,788.68 / $2,367.37 / $2,367.37
| Professional | | $1,788.68 | $2,367.37 | $2,367.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $2,998.57 / $3,797.39
| Professional | | $2,100.00 | $2,998.57 | $3,797.39 |
- 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
- $1,672.57 / $2,409.91 / $3,708.56
| Professional | | $1,672.57 | $2,409.91 | $3,708.56 |