- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,106.00 / $11,548.00 / $19,974.00
| Facility | | $6,106.00 | $11,548.00 | $19,974.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.58 / $416.28 / $685.33
| Professional | | $304.58 | $416.28 | $685.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $692.56 / $150,403.79 / $150,403.79
| Facility | | $692.56 | $150,403.79 | $150,403.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.23 / $2,006.23 / $2,105.28
| Professional | | $2,006.23 | $2,006.23 | $2,105.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.18 / $485.43 / $703.40
| Professional | | $313.18 | $485.43 | $703.40 |