- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $593.78 / $1,850.00 / $3,945.00
| Facility | | $593.78 | $1,850.00 | $3,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.44 / $567.36 / $646.79
| Professional | | $519.44 | $567.36 | $646.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,672.72 / $6,994.86 / $14,571.45
| Facility | | $3,672.72 | $6,994.86 | $14,571.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,039.00 / $3,820.00 / $8,679.40
| Facility | | $1,039.00 | $3,820.00 | $8,679.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.42 / $834.13 / $1,234.91
| Professional | | $542.42 | $834.13 | $1,234.91 |