- 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
- $154.93 / $208.05 / $276.72
| Professional | | $154.93 | $208.05 | $276.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.51 / $250.94 / $378.29
| Professional | | $161.51 | $250.94 | $378.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.72 / $289.43 / $554.27
| Professional | | $190.72 | $289.43 | $554.27 |
- 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
- $222.02 / $329.73 / $512.38
| Professional | | $222.02 | $329.73 | $512.38 |