- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $690.36 / $2,562.00 / $4,050.00
| Facility | | $690.36 | $2,562.00 | $4,050.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.93 / $690.36 / $787.01
| Professional | | $431.93 | $690.36 | $787.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,023.02 / $7,748.72 / $11,678.66
| Facility | | $4,023.02 | $7,748.72 | $11,678.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,141.00 / $4,717.00 / $10,810.00
| Facility | | $1,141.00 | $4,717.00 | $10,810.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.34 / $829.64 / $1,403.66
| Professional | | $623.34 | $829.64 | $1,403.66 |