- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $646.00 / $1,524.00 / $3,728.00
| Facility | | $646.00 | $1,524.00 | $3,728.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.20 / $1,446.22 / $1,648.69
| Professional | | $1,302.20 | $1,446.22 | $1,648.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,377.64 / $9,262.71 / $14,464.60
| Facility | | $4,377.64 | $9,262.71 | $14,464.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $385.00 / $1,309.00 / $7,168.00
| Facility | | $385.00 | $1,309.00 | $7,168.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,289.51 / $1,800.16 / $2,878.14
| Professional | | $1,289.51 | $1,800.16 | $2,878.14 |