- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,738.91 / $5,553.46 / $9,828.00
| Facility | | $2,738.91 | $5,553.46 | $9,828.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $402.32
| Professional | | $402.32 | $402.32 | $402.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.93 / $1,054.93 / $1,054.93
| Professional | | $1,054.93 | $1,054.93 | $1,054.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $482.78
| Facility | | $402.32 | $402.32 | $482.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.00 / $840.00 / $840.00
| Professional | | $840.00 | $840.00 | $840.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $1,874.50
| Facility | | $100.00 | $100.00 | $1,874.50 |