- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,090.00 / $6,607.00 / $9,637.10
| Facility | | $4,090.00 | $6,607.00 | $9,637.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $647.35
| Professional | | $50.00 | $50.00 | $647.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,920.00 / $11,936.00 / $15,915.00
| Facility | | $9,920.00 | $11,936.00 | $15,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.75 / $1,096.73 / $2,249.46
| Professional | | $837.75 | $1,096.73 | $2,249.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,944.00 / $10,417.00 / $16,323.00
| Facility | | $5,944.00 | $10,417.00 | $16,323.00 |