- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $762.00 / $2,125.00 / $4,878.00
| Facility | | $762.00 | $2,125.00 | $4,878.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $665.00 / $3,236.00 / $5,607.00
| Professional | | $665.00 | $3,236.00 | $5,607.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,132.82 / $7,649.42 / $11,085.63
| Facility | | $4,132.82 | $7,649.42 | $11,085.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,028.78 / $5,028.78 / $5,028.78
| Facility | | $5,028.78 | $5,028.78 | $5,028.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,141.00 / $4,717.00 / $10,810.00
| Facility | | $1,141.00 | $4,717.00 | $10,810.00 |