- 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
- $131.69 / $183.15 / $242.33
| Professional | | $131.69 | $183.15 | $242.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.01 / $220.29 / $334.84
| Professional | | $163.01 | $220.29 | $334.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.82 / $254.48 / $488.97
| Professional | | $162.82 | $254.48 | $488.97 |
- 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
- $189.33 / $244.69 / $449.21
| Professional | | $189.33 | $244.69 | $449.21 |