- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $355.32 / $621.05 / $6,426.59
| Facility | | $355.32 | $621.05 | $6,426.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.31 / $225.20 / $316.12
| Professional | | $134.31 | $225.20 | $316.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,133.21 / $2,133.21 / $2,133.21
| Facility | | $2,133.21 | $2,133.21 | $2,133.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.90 / $254.76 / $437.91
| Professional | | $131.90 | $254.76 | $437.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,200.00
| Facility | | $2,200.00 | $2,200.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.37 / $503.54 / $605.30
| Professional | | $220.37 | $503.54 | $605.30 |