- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,430.71 / $4,378.39
| Facility | | $1,277.00 | $2,430.71 | $4,378.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,931.08 / $2,477.52 / $2,785.20
| Professional | | $1,931.08 | $2,477.52 | $2,785.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.47 / $2,621.21 / $2,621.21
| Professional | | $1,980.47 | $2,621.21 | $2,621.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $3,210.67 / $4,241.84
| Professional | | $2,100.00 | $3,210.67 | $4,241.84 |
- 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
- $1,736.88 / $2,324.88 / $4,141.85
| Professional | | $1,736.88 | $2,324.88 | $4,141.85 |