- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,764.96 / $4,921.75
| Facility | | $1,277.00 | $2,764.96 | $4,921.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,300.21 / $2,794.34 / $3,198.23
| Professional | | $2,300.21 | $2,794.34 | $3,198.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,226.34 / $2,946.63 / $2,946.63
| Professional | | $2,226.34 | $2,946.63 | $2,946.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,769.71 / $4,015.63 / $4,885.00
| Professional | | $2,769.71 | $4,015.63 | $4,885.00 |
- 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
- $2,178.15 / $2,492.78 / $4,639.62
| Professional | | $2,178.15 | $2,492.78 | $4,639.62 |