- 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
- $176.77 / $268.08 / $381.21
| Professional | | $176.77 | $268.08 | $381.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.47 / $405.28 / $564.92
| Professional | | $270.47 | $405.28 | $564.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.89 / $442.68 / $696.08
| Professional | | $267.89 | $442.68 | $696.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.95 / $403.19 / $745.66
| Professional | | $296.95 | $403.19 | $745.66 |