- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,544.00 / $7,838.38 / $8,763.29
| Facility | | $1,544.00 | $7,838.38 | $8,763.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,447.25 / $5,253.70 / $5,465.25
| Professional | | $3,447.25 | $5,253.70 | $5,465.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $85.00 / $12,765.54
| Professional | | $60.00 | $85.00 | $12,765.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,609.00 / $21,608.00 / $23,186.00
| Facility | | $10,609.00 | $21,608.00 | $23,186.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.93 / $1,438.01 / $2,499.26
| Professional | | $943.93 | $1,438.01 | $2,499.26 |