- 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
- $75.95 / $128.38 / $293.85
| Professional | | $75.95 | $128.38 | $293.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.61 / $219.30 / $420.92
| Professional | | $115.61 | $219.30 | $420.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.68 / $211.60 / $559.52
| Professional | | $116.68 | $211.60 | $559.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.00 / $1,788.00 / $4,602.00
| Facility | | $1,069.00 | $1,788.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.58 / $387.84 / $601.65
| Professional | | $262.58 | $387.84 | $601.65 |