- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.28 / $6,986.00 / $11,798.00
| Facility | | $1,395.28 | $6,986.00 | $11,798.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.35 / $1,395.28 / $1,395.28
| Professional | | $970.35 | $1,395.28 | $1,395.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $473.45 / $1,023.27 / $1,869.47
| Professional | | $473.45 | $1,023.27 | $1,869.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.42 / $1,492.15 / $2,918.02
| Professional | | $1,122.42 | $1,492.15 | $2,918.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,682.00 / $10,536.00 / $23,291.00
| Facility | | $5,682.00 | $10,536.00 | $23,291.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.74 / $1,712.67 / $3,391.40
| Professional | | $864.74 | $1,712.67 | $3,391.40 |