- 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
- $163.63 / $260.57 / $344.46
| Professional | | $163.63 | $260.57 | $344.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.37 / $379.10 / $531.65
| Professional | | $265.37 | $379.10 | $531.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.45 / $461.17 / $692.07
| Professional | | $187.45 | $461.17 | $692.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.39 / $392.81 / $629.48
| Professional | | $276.39 | $392.81 | $629.48 |