- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,136.71 / $3,754.55
| Facility | | $1,277.00 | $2,136.71 | $3,754.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,709.53 / $2,136.71 / $2,701.79
| Professional | | $1,709.53 | $2,136.71 | $2,701.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,692.48 / $2,240.05 / $2,240.05
| Professional | | $1,692.48 | $2,240.05 | $2,240.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,096.73 / $2,961.52 / $3,660.00
| Professional | | $2,096.73 | $2,961.52 | $3,660.00 |
- 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
- $1,637.99 / $2,356.48 / $3,574.36
| Professional | | $1,637.99 | $2,356.48 | $3,574.36 |