- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,279.85 / $4,031.85
| Facility | | $1,277.00 | $2,279.85 | $4,031.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,777.37 / $2,279.85 / $2,701.08
| Professional | | $1,777.37 | $2,279.85 | $2,701.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,823.89 / $2,413.96 / $2,413.96
| Professional | | $1,823.89 | $2,413.96 | $2,413.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,259.26 / $3,064.01 / $3,904.76
| Professional | | $2,259.26 | $3,064.01 | $3,904.76 |
- 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
- $1,774.89 / $2,046.28 / $3,780.20
| Professional | | $1,774.89 | $2,046.28 | $3,780.20 |