- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $709.16 / $1,100.00 / $2,034.89
| Facility | | $709.16 | $1,100.00 | $2,034.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.85 / $475.00 / $600.00
| Professional | | $132.85 | $475.00 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.02 / $153.50 / $273.83
| Professional | | $93.02 | $153.50 | $273.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,010.25 / $2,010.25 / $2,010.25
| Professional | | $2,010.25 | $2,010.25 | $2,010.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,100.00 / $1,100.00 / $2,034.89
| Facility | | $1,100.00 | $1,100.00 | $2,034.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.50 / $494.18 / $1,016.00
| Professional | | $370.50 | $494.18 | $1,016.00 |