- 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
- $192.63 / $243.67 / $322.89
| Professional | | $192.63 | $243.67 | $322.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.75 / $313.52 / $443.76
| Professional | | $201.75 | $313.52 | $443.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.28 / $344.09 / $652.17
| Professional | | $238.28 | $344.09 | $652.17 |
- 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
- $247.10 / $404.21 / $699.19
| Professional | | $247.10 | $404.21 | $699.19 |