- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,706.14 / $5,702.51
| Facility | | $2,090.73 | $3,706.14 | $5,702.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.37 / $263.95 / $395.45
| Professional | | $137.37 | $263.95 | $395.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.63 / $261.37 / $436.62
| Professional | | $163.63 | $261.37 | $436.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $272.73 / $604.44
| Professional | | $150.00 | $272.73 | $604.44 |
- 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
- $267.04 / $418.98 / $649.46
| Professional | | $267.04 | $418.98 | $649.46 |