- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.00 / $2,493.00 / $9,477.00
| Facility | | $1,181.00 | $2,493.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,178.56 / $4,099.47 / $5,083.14
| Professional | | $3,178.56 | $4,099.47 | $5,083.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,987.32 / $3,953.81 / $3,953.81
| Professional | | $2,987.32 | $3,953.81 | $3,953.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,056.40 / $5,533.30 / $7,104.81
| Professional | | $4,056.40 | $5,533.30 | $7,104.81 |
- 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
- $3,122.21 / $4,384.64 / $6,860.77
| Professional | | $3,122.21 | $4,384.64 | $6,860.77 |