- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,442.12 / $4,431.30
| Facility | | $1,277.00 | $2,442.12 | $4,431.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.72 / $2,473.29 / $4,431.30
| Professional | | $2,031.72 | $2,473.29 | $4,431.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,959.70 / $3,917.25 / $3,917.25
| Professional | | $2,959.70 | $3,917.25 | $3,917.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,715.00 / $3,559.26 / $4,499.21
| Professional | | $2,715.00 | $3,559.26 | $4,499.21 |
- 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
- $1,772.52 / $2,236.66 / $4,044.63
| Professional | | $1,772.52 | $2,236.66 | $4,044.63 |