- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,021.00 / $1,479.33 / $4,057.83
| Facility | | $1,021.00 | $1,479.33 | $4,057.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.00 / $751.10 / $1,479.33
| Professional | | $560.00 | $751.10 | $1,479.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $3.23
| Professional | | $0.02 | $0.02 | $3.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.86 / $520.86 / $520.86
| Professional | | $520.86 | $520.86 | $520.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,410.89 / $2,371.46 / $3,328.36
| Professional | | $1,410.89 | $2,371.46 | $3,328.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $3,000.00 / $4,410.00
| Professional | | $2,500.00 | $3,000.00 | $4,410.00 |