- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.20 / $128.97 / $175.44
| Professional | | $116.20 | $128.97 | $175.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.91 / $193.13 / $227.21
| Professional | | $136.91 | $193.13 | $227.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $207.86 / $297.45
| Professional | | $150.00 | $207.86 | $297.45 |
- 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
- $138.03 / $206.20 / $318.45
| Professional | | $138.03 | $206.20 | $318.45 |