- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.92 / $860.66 / $5,816.00
| Facility | | $23.92 | $860.66 | $5,816.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.60 / $876.04 / $876.04
| Professional | | $752.60 | $876.04 | $876.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,732.57 / $1,732.57 / $1,732.57
| Facility | | $1,732.57 | $1,732.57 | $1,732.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $701.46 / $874.75 / $1,408.15
| Professional | | $701.46 | $874.75 | $1,408.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,200.00
| Facility | | $2,200.00 | $2,200.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.61 / $759.81 / $1,885.60
| Professional | | $623.61 | $759.81 | $1,885.60 |