- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,715.00 / $5,192.00 / $10,692.00
| Facility | | $1,715.00 | $5,192.00 | $10,692.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.84 / $674.41 / $761.68
| Professional | | $509.84 | $674.41 | $761.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.09 / $702.56 / $1,043.38
| Professional | | $513.09 | $702.56 | $1,043.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,846.00 / $7,273.00 / $10,536.00
| Facility | | $1,846.00 | $7,273.00 | $10,536.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.47 / $616.41 / $1,195.22
| Professional | | $342.47 | $616.41 | $1,195.22 |