- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.00 / $4,100.00 / $6,456.00
| Facility | | $1,017.00 | $4,100.00 | $6,456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.46 / $243.46 / $243.46
| Professional | | $243.46 | $243.46 | $243.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.83 / $1,428.83 / $1,428.83
| Professional | | $1,428.83 | $1,428.83 | $1,428.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,648.00 / $3,378.00 / $26,408.00
| Facility | | $2,648.00 | $3,378.00 | $26,408.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.02 / $345.35 / $1,882.09
| Professional | | $221.02 | $345.35 | $1,882.09 |