- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.54 / $4,140.05 / $5,189.46
| Facility | | $81.54 | $4,140.05 | $5,189.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.08 / $7,256.78 / $12,685.12
| Professional | | $1,645.08 | $7,256.78 | $12,685.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.00 / $2,675.00 / $2,675.00
| Professional | | $2,675.00 | $2,675.00 | $2,675.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.00 / $599.00 / $2,530.00
| Facility | | $582.00 | $599.00 | $2,530.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.00 / $322.00 / $1,008.00
| Facility | | $214.00 | $322.00 | $1,008.00 |