- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.00 / $1,821.00 / $9,477.00
| Facility | | $1,181.00 | $1,821.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.48 / $1,604.08 / $2,472.35
| Professional | | $1,221.48 | $1,604.08 | $2,472.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,938.41 / $2,823.48 / $3,895.13
| Professional | | $1,938.41 | $2,823.48 | $3,895.13 |
- 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
- $1,281.78 / $1,688.27 / $3,020.11
| Professional | | $1,281.78 | $1,688.27 | $3,020.11 |