- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.69 / $2,441.98 / $3,938.82
| Facility | | $2,089.69 | $2,441.98 | $3,938.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,515.47 / $1,913.18 / $3,997.42
| Professional | | $1,515.47 | $1,913.18 | $3,997.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.00 / $7,587.00 / $7,587.00
| Professional | | $1,286.00 | $7,587.00 | $7,587.00 |
- 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
- $5,448.50 / $5,448.50 / $5,448.50
| Facility | | $5,448.50 | $5,448.50 | $5,448.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,393.75 / $7,587.00 / $7,587.00
| Professional | | $3,393.75 | $7,587.00 | $7,587.00 |