- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,744.00 / $3,696.90 / $5,743.00
| Facility | | $2,744.00 | $3,696.90 | $5,743.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.59 / $502.36 / $7,414.50
| Professional | | $125.59 | $502.36 | $7,414.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $866.93
| Professional | | $45.00 | $45.00 | $866.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $894.19 / $1,191.10 / $1,735.80
| Facility | | $894.19 | $1,191.10 | $1,735.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.00 / $1,649.00 / $2,824.00
| Facility | | $1,106.00 | $1,649.00 | $2,824.00 |