- 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
- $141.29 / $191.46 / $252.74
| Professional | | $141.29 | $191.46 | $252.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.65 / $233.78 / $305.97
| Professional | | $163.65 | $233.78 | $305.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $279.47 / $399.26
| Professional | | $150.00 | $279.47 | $399.26 |
- 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
- $153.59 / $276.76 / $443.59
| Professional | | $153.59 | $276.76 | $443.59 |