- 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
- $150.16 / $270.06 / $433.57
| Professional | | $150.16 | $270.06 | $433.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.30 / $289.11 / $444.77
| Professional | | $166.30 | $289.11 | $444.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.44 / $329.72 / $594.02
| Professional | | $238.44 | $329.72 | $594.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.68 / $378.54 / $635.53
| Professional | | $209.68 | $378.54 | $635.53 |