- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,644.85 / $4,491.75 / $10,651.00
| Facility | | $1,644.85 | $4,491.75 | $10,651.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.00 / $7,124.26 / $8,941.18
| Professional | | $600.00 | $7,124.26 | $8,941.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,285.00 / $4,974.00 / $26,120.00
| Facility | | $2,285.00 | $4,974.00 | $26,120.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,871.54 / $9,871.54 / $9,871.54
| Professional | | $9,871.54 | $9,871.54 | $9,871.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,251.00 / $11,924.00 / $19,737.00
| Facility | | $9,251.00 | $11,924.00 | $19,737.00 |