- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.00 / $2,145.78 / $7,838.38
| Facility | | $1,047.00 | $2,145.78 | $7,838.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,271.82 / $3,479.76 / $3,500.49
| Professional | | $3,271.82 | $3,479.76 | $3,500.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $85.00 / $5,036.99
| Professional | | $60.00 | $85.00 | $5,036.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,358.52 / $4,358.52 / $4,358.52
| Facility | | $4,358.52 | $4,358.52 | $4,358.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,085.00 / $3,085.00 / $5,060.00
| Facility | | $3,085.00 | $3,085.00 | $5,060.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,708.55 / $5,694.14 / $8,178.87
| Professional | | $4,708.55 | $5,694.14 | $8,178.87 |