- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $518.33 / $1,520.00 / $3,728.00
| Facility | | $518.33 | $1,520.00 | $3,728.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.33 / $518.33 / $518.33
| Professional | | $518.33 | $518.33 | $518.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,792.79 / $8,079.52 / $12,665.76
| Facility | | $4,792.79 | $8,079.52 | $12,665.76 |
- 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
- $156.84 / $245.74 / $434.22
| Professional | | $156.84 | $245.74 | $434.22 |