- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,605.86 / $4,387.00 / $8,344.00
| Facility | | $1,605.86 | $4,387.00 | $8,344.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,605.86 / $1,605.86 / $1,811.41
| Professional | | $1,605.86 | $1,605.86 | $1,811.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.30 / $2,116.30 / $2,116.30
| Professional | | $2,116.30 | $2,116.30 | $2,116.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,298.64 / $9,810.86 / $14,297.23
| Facility | | $7,298.64 | $9,810.86 | $14,297.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.00 / $3,613.00 / $7,048.00
| Facility | | $1,981.00 | $3,613.00 | $7,048.00 |