- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,074.00 / $4,280.34 / $8,031.00
| Facility | | $2,074.00 | $4,280.34 | $8,031.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $333.09 / $401.15 / $401.15
| Professional | | $333.09 | $401.15 | $401.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.13 / $220.77 / $364.98
| Professional | | $151.13 | $220.77 | $364.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,347.00 / $3,983.00 / $6,832.00
| Facility | | $1,347.00 | $3,983.00 | $6,832.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.66 / $402.28 / $965.83
| Professional | | $296.66 | $402.28 | $965.83 |