- 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
- $279.67 / $285.48 / $384.34
| Professional | | $279.67 | $285.48 | $384.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.58 / $338.33 / $546.03
| Professional | | $287.58 | $338.33 | $546.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $395.10 / $577.59
| Professional | | $150.00 | $395.10 | $577.59 |
- 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
- $287.58 / $397.80 / $640.12
| Professional | | $287.58 | $397.80 | $640.12 |