- 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
- $212.28 / $216.51 / $289.33
| Professional | | $212.28 | $216.51 | $289.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.39 / $256.93 / $412.69
| Professional | | $218.39 | $256.93 | $412.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $294.22 / $435.64
| Professional | | $150.00 | $294.22 | $435.64 |
- 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
- $215.82 / $291.27 / $411.23
| Professional | | $215.82 | $291.27 | $411.23 |