- 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
- $135.51 / $193.83 / $305.33
| Professional | | $135.51 | $193.83 | $305.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.91 / $222.19 / $390.16
| Professional | | $151.91 | $222.19 | $390.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.28 / $282.70 / $420.15
| Professional | | $205.28 | $282.70 | $420.15 |
- 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
- $172.87 / $301.36 / $449.67
| Professional | | $172.87 | $301.36 | $449.67 |