- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $569.23 / $1,821.00 / $9,477.00
| Facility | | $569.23 | $1,821.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.23 / $1,452.30 / $2,659.27
| Professional | | $569.23 | $1,452.30 | $2,659.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.74 / $748.14 / $2,439.14
| Professional | | $508.74 | $748.14 | $2,439.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,221.52 / $2,221.52 / $2,221.52
| Facility | | $2,221.52 | $2,221.52 | $2,221.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,240.00 / $2,311.00 / $5,626.00
| Facility | | $1,240.00 | $2,311.00 | $5,626.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.02 / $1,574.57 / $3,383.01
| Professional | | $600.02 | $1,574.57 | $3,383.01 |