- 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
- $201.50 / $293.45 / $391.16
| Professional | | $201.50 | $293.45 | $391.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.73 / $384.51 / $459.60
| Professional | | $240.73 | $384.51 | $459.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.66 / $402.76 / $677.84
| Professional | | $167.66 | $402.76 | $677.84 |
- 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
- $294.75 / $439.75 / $715.18
| Professional | | $294.75 | $439.75 | $715.18 |