- 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
- $239.68 / $378.14 / $597.80
| Professional | | $239.68 | $378.14 | $597.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.89 / $386.77 / $681.62
| Professional | | $258.89 | $386.77 | $681.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.24 / $473.26 / $804.71
| Professional | | $359.24 | $473.26 | $804.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,080.00 / $3,912.00 / $7,350.00
| Facility | | $2,080.00 | $3,912.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.11 / $562.41 / $869.36
| Professional | | $331.11 | $562.41 | $869.36 |