- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,736.00 / $4,736.00 / $6,907.00
| Facility | | $4,736.00 | $4,736.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.25 / $267.25 / $306.12
| Professional | | $267.25 | $267.25 | $306.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.94 / $370.82 / $525.99
| Professional | | $272.94 | $370.82 | $525.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,565.42 / $2,565.42 / $3,420.39
| Facility | | $2,565.42 | $2,565.42 | $3,420.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.37 / $355.07 / $682.62
| Professional | | $274.37 | $355.07 | $682.62 |