- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.00 / $2,378.09 / $9,477.00
| Facility | | $1,181.00 | $2,378.09 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,841.01 / $2,378.09 / $2,902.17
| Professional | | $1,841.01 | $2,378.09 | $2,902.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.86 / $2,474.82 / $2,474.82
| Professional | | $1,869.86 | $2,474.82 | $2,474.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,350.66 / $3,242.60 / $4,063.62
| Professional | | $2,350.66 | $3,242.60 | $4,063.62 |
- 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
- $1,842.30 / $3,257.39 / $4,058.77
| Professional | | $1,842.30 | $3,257.39 | $4,058.77 |