- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,164.46 / $4,392.07
| Facility | | $1,277.00 | $2,164.46 | $4,392.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.78 / $2,517.17 / $3,028.59
| Professional | | $1,465.78 | $2,517.17 | $3,028.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,960.24 / $3,917.97 / $3,917.97
| Professional | | $2,960.24 | $3,917.97 | $3,917.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,825.00 / $3,554.49 / $4,526.56
| Professional | | $1,825.00 | $3,554.49 | $4,526.56 |
- 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
- $1,686.70 / $2,297.52 / $4,167.50
| Professional | | $1,686.70 | $2,297.52 | $4,167.50 |