- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.68 / $174.86 / $193.07
| Professional | | $85.68 | $174.86 | $193.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.36 / $179.25 / $254.84
| Professional | | $152.36 | $179.25 | $254.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.33 / $223.66 / $389.14
| Professional | | $118.33 | $223.66 | $389.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,596.00 / $7,457.00 / $12,945.00
| Facility | | $4,596.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.65 / $199.69 / $312.56
| Professional | | $168.65 | $199.69 | $312.56 |