- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $244.16 / $3,706.14 / $5,695.56
| Facility | | $244.16 | $3,706.14 | $5,695.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.30 / $780.00 / $780.00
| Professional | | $673.30 | $780.00 | $780.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.25 / $362.25 / $362.25
| Professional | | $362.25 | $362.25 | $362.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,074.00 / $7,819.00 / $17,123.00
| Facility | | $5,074.00 | $7,819.00 | $17,123.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41,404.26 / $41,404.26 / $41,404.26
| Professional | | $41,404.26 | $41,404.26 | $41,404.26 |