- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,652.17 / $5,982.00 / $10,871.00
| Facility | | $1,652.17 | $5,982.00 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.17 / $1,652.17 / $1,652.17
| Professional | | $1,652.17 | $1,652.17 | $1,652.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.00 / $805.00 / $1,059.86
| Professional | | $553.00 | $805.00 | $1,059.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.84 / $1,254.84 / $1,254.84
| Professional | | $1,254.84 | $1,254.84 | $1,254.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,627.00 / $6,590.00 / $10,536.00
| Facility | | $1,627.00 | $6,590.00 | $10,536.00 |