- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,570.69 / $4,757.67
| Facility | | $1,277.00 | $2,570.69 | $4,757.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,206.71 / $2,670.47 / $3,270.16
| Professional | | $2,206.71 | $2,670.47 | $3,270.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,177.60 / $4,205.64 / $4,205.64
| Professional | | $3,177.60 | $4,205.64 | $4,205.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,907.53 / $3,916.17 / $4,849.56
| Professional | | $2,907.53 | $3,916.17 | $4,849.56 |
- 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
- $1,945.31 / $2,624.91 / $4,493.53
| Professional | | $1,945.31 | $2,624.91 | $4,493.53 |