- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,946.00 / $9,472.00 / $17,487.00
| Facility | | $5,946.00 | $9,472.00 | $17,487.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.56 / $1,505.64 / $2,087.19
| Professional | | $1,161.56 | $1,505.64 | $2,087.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $886.70 / $989.02 / $2,031.32
| Facility | | $886.70 | $989.02 | $2,031.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.52 / $1,640.68 / $2,693.03
| Professional | | $893.52 | $1,640.68 | $2,693.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.00 / $1,202.00 / $1,202.00
| Facility | | $1,202.00 | $1,202.00 | $1,202.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.60 / $1,853.82 / $2,990.03
| Professional | | $1,325.60 | $1,853.82 | $2,990.03 |