- 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
- $170.76 / $180.23 / $234.47
| Professional | | $170.76 | $180.23 | $234.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.24 / $224.99 / $345.02
| Professional | | $191.24 | $224.99 | $345.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $255.00 / $364.94
| Professional | | $150.00 | $255.00 | $364.94 |
- 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
- $171.18 / $252.97 / $375.31
| Professional | | $171.18 | $252.97 | $375.31 |