- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.00 / $3,202.26 / $6,907.00
| Facility | | $3,140.00 | $3,202.26 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.14 / $206.47 / $206.47
| Professional | | $202.14 | $206.47 | $206.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.45 / $260.95 / $380.44
| Professional | | $189.45 | $260.95 | $380.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,565.42 / $2,565.42 / $3,420.94
| Facility | | $2,565.42 | $2,565.42 | $3,420.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.76 / $253.87 / $459.96
| Professional | | $178.76 | $253.87 | $459.96 |