- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,974.00 / $4,736.00 / $6,907.00
| Facility | | $3,974.00 | $4,736.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.60 / $299.94 / $331.80
| Professional | | $165.60 | $299.94 | $331.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.55 / $315.44 / $485.28
| Professional | | $181.55 | $315.44 | $485.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,003.85 / $7,003.85 / $7,003.85
| Facility | | $7,003.85 | $7,003.85 | $7,003.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.07 / $471.47 / $781.12
| Professional | | $343.07 | $471.47 | $781.12 |