- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $2,238.72 / $3,090.30
| Facility | | $162.18 | $2,238.72 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $218.78 / $1,862.09
| Professional | | $144.54 | $218.78 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Facility | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $223.87
| Professional | | $173.78 | $173.78 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $3,548.13
| Professional | | $2,187.76 | $2,187.76 | $3,548.13 |