- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,706.14 / $4,751.58
| Facility | | $2,090.73 | $3,706.14 | $4,751.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.94 / $252.25 / $347.71
| Professional | | $110.94 | $252.25 | $347.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.77 / $285.95 / $514.60
| Professional | | $153.77 | $285.95 | $514.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.08 / $270.56 / $496.36
| Professional | | $161.08 | $270.56 | $496.36 |
- 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
- $239.24 / $345.44 / $506.71
| Professional | | $239.24 | $345.44 | $506.71 |