- 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
- $137.68 / $149.66 / $201.51
| Professional | | $137.68 | $149.66 | $201.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.78 / $233.95 / $266.06
| Professional | | $170.78 | $233.95 | $266.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.19 / $249.66 / $373.29
| Professional | | $152.19 | $249.66 | $373.29 |
- 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
- $158.61 / $250.27 / $406.84
| Professional | | $158.61 | $250.27 | $406.84 |