- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.00 / $3,637.47 / $4,601.00
| Facility | | $1,017.00 | $3,637.47 | $4,601.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.49 / $242.78 / $3,637.47
| Professional | | $58.49 | $242.78 | $3,637.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.48 / $66.12 / $68.09
| Professional | | $61.48 | $66.12 | $68.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,301.13 / $7,483.93 / $7,521.27
| Professional | | $6,301.13 | $7,483.93 | $7,521.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.00 / $442.00 / $5,940.00
| Facility | | $165.00 | $442.00 | $5,940.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.20 / $2,126.48 / $6,004.20
| Professional | | $1,473.20 | $2,126.48 | $6,004.20 |