- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.15 / $845.86 / $3,949.00
| Facility | | $202.15 | $845.86 | $3,949.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.59 / $526.85 / $845.86
| Professional | | $173.59 | $526.85 | $845.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.82 / $372.41 / $1,465.02
| Professional | | $170.82 | $372.41 | $1,465.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,132.00 / $6,132.00 / $12,165.11
| Facility | | $6,132.00 | $6,132.00 | $12,165.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $744.76 / $1,728.04 / $1,801.24
| Professional | | $744.76 | $1,728.04 | $1,801.24 |