- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,246.25 / $1,456.34 / $2,349.03
| Facility | | $1,246.25 | $1,456.34 | $2,349.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.16 / $1,312.53 / $1,989.77
| Professional | | $940.16 | $1,312.53 | $1,989.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.00 / $3,807.00 / $3,807.00
| Professional | | $971.00 | $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
- $1,968.66 / $1,968.66 / $1,968.66
| Facility | | $1,968.66 | $1,968.66 | $1,968.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.10 / $3,807.00 / $3,807.00
| Professional | | $1,819.10 | $3,807.00 | $3,807.00 |