- 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
- $142.60 / $326.48 / $583.26
| Professional | | $142.60 | $326.48 | $583.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.10 / $428.52 / $819.93
| Professional | | $214.10 | $428.52 | $819.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.88 / $414.68 / $1,068.15
| Professional | | $215.88 | $414.68 | $1,068.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $532.67 / $740.40 / $1,149.30
| Professional | | $532.67 | $740.40 | $1,149.30 |