- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.78 / $4,755.00 / $11,624.00
| Facility | | $1,201.78 | $4,755.00 | $11,624.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.78 / $1,201.78 / $1,507.37
| Professional | | $1,201.78 | $1,201.78 | $1,507.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $323.00
| Facility | | $64.00 | $64.00 | $323.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,559.67 / $1,663.65 / $1,798.82
| Facility | | $1,559.67 | $1,663.65 | $1,798.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $351.00 / $1,954.00 / $5,107.00
| Facility | | $351.00 | $1,954.00 | $5,107.00 |