- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.29 / $552.05 / $3,949.00
| Facility | | $407.29 | $552.05 | $3,949.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.47 / $167.86 / $220.32
| Professional | | $158.47 | $167.86 | $220.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.38 / $219.32 / $313.02
| Professional | | $153.38 | $219.32 | $313.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,967.41 / $9,967.41 / $9,967.41
| Facility | | $9,967.41 | $9,967.41 | $9,967.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.66 / $232.59 / $477.84
| Professional | | $177.66 | $232.59 | $477.84 |