- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,601.13 / $2,244.38 / $6,907.00
| Facility | | $1,601.13 | $2,244.38 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.03 / $154.41 / $154.81
| Professional | | $150.03 | $154.41 | $154.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.46 / $200.64 / $276.44
| Professional | | $143.46 | $200.64 | $276.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,584.97 / $3,584.97 / $3,584.97
| Facility | | $3,584.97 | $3,584.97 | $3,584.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.38 / $190.64 / $352.50
| Professional | | $130.38 | $190.64 | $352.50 |