- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,244.31 / $4,100.00 / $6,456.00
| Facility | | $1,244.31 | $4,100.00 | $6,456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.31 / $1,244.31 / $1,244.31
| Professional | | $1,244.31 | $1,244.31 | $1,244.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,148.06 / $3,148.06 / $3,148.06
| Professional | | $3,148.06 | $3,148.06 | $3,148.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,648.00 / $3,378.00 / $26,408.00
| Facility | | $2,648.00 | $3,378.00 | $26,408.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.38 / $3,850.41 / $5,226.04
| Professional | | $1,835.38 | $3,850.41 | $5,226.04 |