- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.24 / $4,004.00 / $4,601.00
| Facility | | $1,380.24 | $4,004.00 | $4,601.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.24 / $1,380.24 / $1,380.24
| Professional | | $1,380.24 | $1,380.24 | $1,380.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.92 / $1,394.92 / $1,468.34
| Professional | | $1,394.92 | $1,394.92 | $1,468.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,832.00 / $2,343.00 / $26,408.00
| Facility | | $1,832.00 | $2,343.00 | $26,408.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.24 / $2,089.53 / $3,645.39
| Professional | | $1,238.24 | $2,089.53 | $3,645.39 |