- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.14 / $3,038.00 / $4,387.00
| Facility | | $1,450.14 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.14 / $1,450.14 / $1,598.59
| Professional | | $1,450.14 | $1,450.14 | $1,598.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $3,333.87
| Professional | | $45.00 | $45.00 | $3,333.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.16 / $2,015.66 / $2,172.42
| Professional | | $1,737.16 | $2,015.66 | $2,172.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,312.00 / $2,446.00 / $13,847.00
| Facility | | $2,312.00 | $2,446.00 | $13,847.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.52 / $1,671.84 / $2,839.67
| Professional | | $1,301.52 | $1,671.84 | $2,839.67 |