- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,157.50 / $2,525.00 / $3,638.00
| Facility | | $1,157.50 | $2,525.00 | $3,638.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.00 / $4,152.74 / $12,836.40
| Professional | | $375.00 | $4,152.74 | $12,836.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.96 / $1,448.88 / $2,540.48
| Facility | | $954.96 | $1,448.88 | $2,540.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.54 / $2,045.42 / $5,147.10
| Facility | | $123.54 | $2,045.42 | $5,147.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.94 / $1,989.90 / $5,085.45
| Professional | | $484.94 | $1,989.90 | $5,085.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,755.00 / $2,872.00 / $4,241.00
| Facility | | $1,755.00 | $2,872.00 | $4,241.00 |