- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $690.12 / $6,325.00 / $11,298.00
| Facility | | $690.12 | $6,325.00 | $11,298.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.61 / $655.61 / $1,240.00
| Professional | | $655.61 | $655.61 | $1,240.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.24 / $3,601.29 / $7,314.01
| Facility | | $2,906.24 | $3,601.29 | $7,314.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.00 / $850.00 / $1,000.00
| Professional | | $850.00 | $850.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,705.00 / $5,265.00 / $10,536.00
| Facility | | $3,705.00 | $5,265.00 | $10,536.00 |