- 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
- $517.15 / $517.15 / $517.15
| Professional | | $517.15 | $517.15 | $517.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.34 / $1,066.34 / $1,066.34
| Professional | | $1,066.34 | $1,066.34 | $1,066.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,840.00 / $12,698.00 / $47,612.00
| Facility | | $7,840.00 | $12,698.00 | $47,612.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $429.76 / $671.50 / $1,341.35
| Professional | | $429.76 | $671.50 | $1,341.35 |