- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,736.00 / $4,873.00 / $6,907.00
| Facility | | $4,736.00 | $4,873.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.82 / $397.43 / $407.65
| Professional | | $298.82 | $397.43 | $407.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.30 / $430.27 / $611.65
| Professional | | $288.30 | $430.27 | $611.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,495.61 / $1,495.61 / $1,495.61
| Facility | | $1,495.61 | $1,495.61 | $1,495.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.93 / $479.06 / $1,053.93
| Professional | | $329.93 | $479.06 | $1,053.93 |