- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,308.46 / $4,052.60
| Facility | | $1,277.00 | $2,308.46 | $4,052.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,821.01 / $2,308.46 / $2,836.82
| Professional | | $1,821.01 | $2,308.46 | $2,836.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.61 / $2,417.57 / $2,417.57
| Professional | | $1,826.61 | $2,417.57 | $2,417.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,267.60 / $3,178.62 / $3,953.86
| Professional | | $2,267.60 | $3,178.62 | $3,953.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,230.00 / $2,421.00
| Facility | | $375.00 | $1,230.00 | $2,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.93 / $2,526.89 / $3,836.44
| Professional | | $1,671.93 | $2,526.89 | $3,836.44 |