- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.00 / $3,999.00 / $6,456.00
| Facility | | $1,017.00 | $3,999.00 | $6,456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.62 / $526.62 / $526.62
| Professional | | $526.62 | $526.62 | $526.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.03 / $1,153.44 / $1,153.44
| Professional | | $533.03 | $1,153.44 | $1,153.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,832.00 / $6,073.00 / $26,408.00
| Facility | | $1,832.00 | $6,073.00 | $26,408.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.83 / $635.65 / $1,419.66
| Professional | | $385.83 | $635.65 | $1,419.66 |