- 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
- $266.58 / $422.46 / $660.44
| Professional | | $266.58 | $422.46 | $660.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.56 / $438.87 / $772.41
| Professional | | $294.56 | $438.87 | $772.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.90 / $530.10 / $905.61
| Professional | | $407.90 | $530.10 | $905.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.51 / $523.32 / $891.20
| Professional | | $348.51 | $523.32 | $891.20 |