- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $323.59 / $630.96
| Professional | | $147.91 | $323.59 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $263.03 / $446.68
| Professional | | $117.49 | $263.03 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $371.54 / $537.03
| Professional | | $173.78 | $371.54 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $331.13 / $524.81
| Professional | | $144.54 | $331.13 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $331.13 / $537.03
| Professional | | $151.36 | $331.13 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $302.00 / $524.81
| Professional | | $177.83 | $302.00 | $524.81 |