- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,614.00 / $4,848.00 / $6,456.00
| Facility | | $1,614.00 | $4,848.00 | $6,456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.08 / $803.08 / $803.08
| Professional | | $803.08 | $803.08 | $803.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,186.00 / $7,513.00 / $12,548.00
| Professional | | $4,186.00 | $7,513.00 | $12,548.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,545.54 / $5,446.08 / $6,557.22
| Professional | | $4,545.54 | $5,446.08 | $6,557.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,261.00 / $4,165.00 / $26,408.00
| Facility | | $3,261.00 | $4,165.00 | $26,408.00 |