- 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
- $94.37 / $223.68 / $417.33
| Professional | | $94.37 | $223.68 | $417.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.80 / $172.57 / $326.69
| Professional | | $96.80 | $172.57 | $326.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.52 / $312.23 / $476.83
| Professional | | $140.52 | $312.23 | $476.83 |
- 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
- $231.07 / $378.85 / $607.95
| Professional | | $231.07 | $378.85 | $607.95 |