- 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
- $94.82 / $155.08 / $205.34
| Professional | | $94.82 | $155.08 | $205.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.05 / $180.85 / $288.98
| Professional | | $113.05 | $180.85 | $288.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.07 / $217.79 / $416.52
| Professional | | $133.07 | $217.79 | $416.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.63 / $230.06 / $380.14
| Professional | | $152.63 | $230.06 | $380.14 |