- 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
- $287.38 / $387.25 / $520.95
| Professional | | $287.38 | $387.25 | $520.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.44 / $515.15 / $625.00
| Professional | | $349.44 | $515.15 | $625.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.45 / $580.89 / $854.07
| Professional | | $246.45 | $580.89 | $854.07 |
- 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
- $377.32 / $584.45 / $914.34
| Professional | | $377.32 | $584.45 | $914.34 |