- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.00 / $2,060.14 / $9,477.00
| Facility | | $1,181.00 | $2,060.14 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,060.14 / $2,060.14 / $2,838.27
| Professional | | $2,060.14 | $2,060.14 | $2,838.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,361.01 / $3,124.87 / $3,124.87
| Professional | | $2,361.01 | $3,124.87 | $3,124.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.00 / $3,392.99 / $4,816.34
| Professional | | $600.00 | $3,392.99 | $4,816.34 |
- 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
- $1,624.07 / $2,584.67 / $4,784.32
| Professional | | $1,624.07 | $2,584.67 | $4,784.32 |