- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $756.00 / $2,574.00 / $4,991.00
| Facility | | $756.00 | $2,574.00 | $4,991.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $665.00 / $3,685.00 / $9,804.54
| Professional | | $665.00 | $3,685.00 | $9,804.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,172.80 / $7,454.00 / $10,637.02
| Facility | | $4,172.80 | $7,454.00 | $10,637.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,314.50 / $12,314.50 / $12,314.50
| Facility | | $12,314.50 | $12,314.50 | $12,314.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $826.00 / $2,653.00 / $6,661.00
| Facility | | $826.00 | $2,653.00 | $6,661.00 |