- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $5,370.32
| Facility | | $2,884.03 | $2,884.03 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $190.55 / $741.31
| Professional | | $138.04 | $190.55 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $131.83 / $158.49
| Professional | | $117.49 | $131.83 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $302.00 / $389.05
| Professional | | $269.15 | $302.00 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $229.09 / $398.11
| Professional | | $151.36 | $229.09 | $398.11 |