- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,765.29 / $2,521.67 / $6,907.00
| Facility | | $1,765.29 | $2,521.67 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.48 / $259.74 / $275.99
| Professional | | $194.48 | $259.74 | $275.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.26 / $320.95 / $474.28
| Professional | | $196.26 | $320.95 | $474.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,565.34 / $2,565.34 / $2,565.34
| Facility | | $2,565.34 | $2,565.34 | $2,565.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,957.28 / $1,957.28 / $1,957.28
| Professional | | $1,957.28 | $1,957.28 | $1,957.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.69 / $329.70 / $639.49
| Professional | | $254.69 | $329.70 | $639.49 |