- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,174.00 / $4,002.00 / $6,183.00
| Facility | | $2,174.00 | $4,002.00 | $6,183.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.64 / $143.22 / $241.71
| Professional | | $105.64 | $143.22 | $241.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,664.30 / $10,710.95 / $10,710.95
| Facility | | $1,664.30 | $10,710.95 | $10,710.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.36 / $1,328.36 / $1,394.85
| Professional | | $1,328.36 | $1,328.36 | $1,394.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.63 / $174.57 / $272.06
| Professional | | $113.63 | $174.57 | $272.06 |