- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.00 / $4,100.00 / $6,945.00
| Facility | | $1,017.00 | $4,100.00 | $6,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.16 / $251.48 / $251.48
| Professional | | $235.16 | $251.48 | $251.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.70 / $294.92 / $551.59
| Professional | | $254.70 | $294.92 | $551.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,261.00 / $4,165.00 / $26,408.00
| Facility | | $3,261.00 | $4,165.00 | $26,408.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.68 / $303.75 / $665.13
| Professional | | $209.68 | $303.75 | $665.13 |