- 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
- $305.07 / $404.27 / $508.18
| Professional | | $305.07 | $404.27 | $508.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.45 / $537.97 / $681.41
| Professional | | $356.45 | $537.97 | $681.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $522.86 / $825.66
| Professional | | $250.00 | $522.86 | $825.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $3,447.00 / $5,685.00
| Facility | | $2,569.00 | $3,447.00 | $5,685.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.52 / $572.32 / $873.42
| Professional | | $313.52 | $572.32 | $873.42 |