- 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
- $147.25 / $156.51 / $227.71
| Professional | | $147.25 | $156.51 | $227.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.26 / $201.34 / $201.34
| Professional | | $152.26 | $201.34 | $201.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $680.00 / $2,086.86
| Facility | | $680.00 | $680.00 | $2,086.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.82 / $253.25 / $357.39
| Professional | | $172.82 | $253.25 | $357.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.08 / $192.62 / $321.39
| Professional | | $147.08 | $192.62 | $321.39 |