- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,905.03 / $5,905.03 / $5,905.03
| Facility | | $5,905.03 | $5,905.03 | $5,905.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.00 / $2,080.00 / $2,497.23
| Professional | | $95.00 | $2,080.00 | $2,497.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.38 / $741.95 / $1,343.72
| Facility | | $205.38 | $741.95 | $1,343.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.04 / $205.38 / $279.83
| Professional | | $154.04 | $205.38 | $279.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.00 / $2,374.87 / $2,374.87
| Facility | | $95.00 | $2,374.87 | $2,374.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,374.87 / $2,374.87 / $2,374.87
| Professional | | $2,374.87 | $2,374.87 | $2,374.87 |