- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,011.87 / $8,511.38
| Facility | | $3,467.37 | $5,011.87 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $1,000.00 / $2,290.87
| Professional | | $95.50 | $1,000.00 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,162.28 / $11,748.98
| Facility | | $2,137.96 | $3,162.28 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $213.80 / $3,162.28
| Professional | | $125.89 | $213.80 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,890.45 / $6,760.83
| Facility | | $1,288.25 | $3,890.45 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $316.23 / $3,890.45
| Professional | | $95.50 | $316.23 | $3,890.45 |