- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,305.00 / $9,255.00 / $17,630.43
| Facility | | $4,305.00 | $9,255.00 | $17,630.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,071.19 / $3,859.17 / $3,918.51
| Professional | | $3,071.19 | $3,859.17 | $3,918.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $367.47 / $367.47 / $367.47
| Facility | | $367.47 | $367.47 | $367.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.50 / $1,326.50 / $3,236.72
| Professional | | $1,326.50 | $1,326.50 | $3,236.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,541.80 / $6,313.47 / $9,894.12
| Facility | | $1,541.80 | $6,313.47 | $9,894.12 |