- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $879.51 / $1,678.00 / $2,250.00
| Facility | | $879.51 | $1,678.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.51 / $991.05 / $1,395.28
| Professional | | $879.51 | $991.05 | $1,395.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,484.66 / $21,218.47 / $28,545.63
| Facility | | $17,484.66 | $21,218.47 | $28,545.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,404.00 / $4,852.00 / $9,624.00
| Facility | | $1,404.00 | $4,852.00 | $9,624.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.15 / $1,086.83 / $2,059.59
| Professional | | $835.15 | $1,086.83 | $2,059.59 |