- 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
- $124.73 / $213.82 / $386.69
| Professional | | $124.73 | $213.82 | $386.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.62 / $228.08 / $384.68
| Professional | | $135.62 | $228.08 | $384.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.40 / $277.47 / $525.19
| Professional | | $197.40 | $277.47 | $525.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,334.00 / $2,445.00 / $4,602.00
| Facility | | $1,334.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.29 / $359.26 / $564.46
| Professional | | $219.29 | $359.26 | $564.46 |