- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.00 / $5,076.00 / $6,945.00
| Facility | | $1,017.00 | $5,076.00 | $6,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.05 / $524.05 / $524.05
| Professional | | $524.05 | $524.05 | $524.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.46 / $1,168.46 / $1,168.46
| Professional | | $1,168.46 | $1,168.46 | $1,168.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29,924.00 / $45,102.00 / $151,718.00
| Facility | | $29,924.00 | $45,102.00 | $151,718.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.71 / $825.73 / $1,523.13
| Professional | | $475.71 | $825.73 | $1,523.13 |