- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,816.00 / $5,816.00 / $6,907.00
| Facility | | $5,816.00 | $5,816.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.05 / $244.43 / $344.18
| Professional | | $240.05 | $244.43 | $344.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,529.91 / $1,529.91 / $2,656.00
| Facility | | $1,529.91 | $1,529.91 | $2,656.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.06 / $291.27 / $436.45
| Professional | | $223.06 | $291.27 | $436.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,027.00 / $1,485.00 / $1,485.00
| Facility | | $1,027.00 | $1,485.00 | $1,485.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.72 / $267.38 / $545.40
| Professional | | $203.72 | $267.38 | $545.40 |