- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.02 / $217.63 / $220.67
| Professional | | $151.02 | $217.63 | $220.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.30 / $230.94 / $383.19
| Professional | | $196.30 | $230.94 | $383.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.72 / $300.00 / $455.34
| Professional | | $148.72 | $300.00 | $455.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.29 / $275.02 / $423.34
| Professional | | $175.29 | $275.02 | $423.34 |