- 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
- $111.24 / $155.09 / $204.06
| Professional | | $111.24 | $155.09 | $204.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.58 / $192.26 / $243.91
| Professional | | $134.58 | $192.26 | $243.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.27 / $223.76 / $323.55
| Professional | | $135.27 | $223.76 | $323.55 |
- 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
- $115.38 / $224.27 / $365.47
| Professional | | $115.38 | $224.27 | $365.47 |