- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $516.77 / $711.58 / $6,907.00
| Facility | | $516.77 | $711.58 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.00 / $266.73 / $285.92
| Professional | | $185.00 | $266.73 | $285.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.84 / $268.14 / $425.63
| Professional | | $173.84 | $268.14 | $425.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,463.81 / $2,463.81 / $2,463.81
| Facility | | $2,463.81 | $2,463.81 | $2,463.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.82 / $335.61 / $624.07
| Professional | | $230.82 | $335.61 | $624.07 |