- 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
- $135.08 / $183.79 / $191.13
| Professional | | $135.08 | $183.79 | $191.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.35 / $196.88 / $343.71
| Professional | | $167.35 | $196.88 | $343.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.19 / $284.81 / $388.58
| Professional | | $128.19 | $284.81 | $388.58 |
- 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
- $159.00 / $249.47 / $383.85
| Professional | | $159.00 | $249.47 | $383.85 |