- 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
- $437.82 / $437.82 / $437.82
| Professional | | $437.82 | $437.82 | $437.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.56 / $978.56 / $978.56
| Professional | | $978.56 | $978.56 | $978.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,840.00 / $10,006.00 / $47,612.00
| Facility | | $7,840.00 | $10,006.00 | $47,612.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.26 / $470.71 / $1,407.10
| Professional | | $301.26 | $470.71 | $1,407.10 |