- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,815.00 / $8,023.00 / $13,961.00
| Facility | | $3,815.00 | $8,023.00 | $13,961.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $992.17 / $1,367.93 / $2,384.84
| Professional | | $992.17 | $1,367.93 | $2,384.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,289.32 / $36,459.75 / $36,459.75
| Facility | | $5,289.32 | $36,459.75 | $36,459.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,960.08 / $19,651.75 / $19,651.75
| Professional | | $5,960.08 | $19,651.75 | $19,651.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.79 / $1,635.06 / $2,624.33
| Professional | | $1,052.79 | $1,635.06 | $2,624.33 |