- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.00 / $2,477.00 / $9,477.00
| Facility | | $1,181.00 | $2,477.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,432.38 / $3,432.38 / $5,344.47
| Professional | | $3,432.38 | $3,432.38 | $5,344.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,259.72 / $3,259.72 / $3,911.66
| Facility | | $3,259.72 | $3,259.72 | $3,911.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.00 / $6,736.23 / $7,306.36
| Professional | | $420.00 | $6,736.23 | $7,306.36 |
- 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
- $3,654.41 / $4,245.82 / $7,755.21
| Professional | | $3,654.41 | $4,245.82 | $7,755.21 |