- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,230.35 / $4,057.80
| Facility | | $1,277.00 | $2,230.35 | $4,057.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,725.91 / $2,255.86 / $2,705.15
| Professional | | $1,725.91 | $2,255.86 | $2,705.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,060.19 / $2,575.25 / $2,726.74
| Professional | | $2,060.19 | $2,575.25 | $2,726.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.81 / $2,802.60 / $3,896.12
| Professional | | $1,997.81 | $2,802.60 | $3,896.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $900.00 / $2,421.00
| Facility | | $375.00 | $900.00 | $2,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,658.34 / $2,199.23 / $3,656.22
| Professional | | $1,658.34 | $2,199.23 | $3,656.22 |