- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,671.00 / $3,819.00 / $6,329.00
| Facility | | $1,671.00 | $3,819.00 | $6,329.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,520.23 / $3,520.23 / $3,520.23
| Professional | | $3,520.23 | $3,520.23 | $3,520.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,763.75 / $6,640.00 / $10,860.55
| Facility | | $1,763.75 | $6,640.00 | $10,860.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $619.62 / $4,105.72 / $8,000.46
| Professional | | $619.62 | $4,105.72 | $8,000.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,520.23 / $3,625.84 / $7,146.07
| Facility | | $3,520.23 | $3,625.84 | $7,146.07 |