- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,180.47 / $1,379.47 / $2,225.04
| Facility | | $1,180.47 | $1,379.47 | $2,225.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.09 / $1,080.75 / $2,258.14
| Professional | | $856.09 | $1,080.75 | $2,258.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.00 / $4,363.00 / $4,363.00
| Professional | | $1,008.00 | $4,363.00 | $4,363.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.40 / $58.40 / $58.40
| Professional | | $58.40 | $58.40 | $58.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,576.84 / $4,576.84 / $4,576.84
| Facility | | $4,576.84 | $4,576.84 | $4,576.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.52 / $4,363.00 / $4,363.00
| Professional | | $1,539.52 | $4,363.00 | $4,363.00 |