- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,092.16 / $1,276.27 / $2,058.58
| Facility | | $1,092.16 | $1,276.27 | $2,058.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.92 / $1,312.53 / $1,743.75
| Professional | | $823.92 | $1,312.53 | $1,743.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.00 / $3,807.00 / $3,807.00
| Professional | | $888.00 | $3,807.00 | $3,807.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $70.00
| Professional | | $50.00 | $50.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,789.32 / $1,789.32 / $1,789.32
| Facility | | $1,789.32 | $1,789.32 | $1,789.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,647.79 / $3,807.00 / $3,807.00
| Professional | | $1,647.79 | $3,807.00 | $3,807.00 |