- 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
- $148.59 / $224.56 / $291.97
| Professional | | $148.59 | $224.56 | $291.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.80 / $273.35 / $448.74
| Professional | | $168.80 | $273.35 | $448.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.74 / $336.26 / $641.79
| Professional | | $207.74 | $336.26 | $641.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.82 / $413.60 / $687.14
| Professional | | $257.82 | $413.60 | $687.14 |