- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,131.00 / $7,655.00 / $13,151.00
| Facility | | $3,131.00 | $7,655.00 | $13,151.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.96 / $236.21 / $307.80
| Professional | | $234.96 | $236.21 | $307.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.31 / $965.31 / $965.31
| Professional | | $965.31 | $965.31 | $965.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.48 / $245.75 / $653.35
| Facility | | $207.48 | $245.75 | $653.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,713.22 / $2,713.22 / $2,713.22
| Professional | | $2,713.22 | $2,713.22 | $2,713.22 |