- 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
- $259.44 / $267.32 / $361.34
| Professional | | $259.44 | $267.32 | $361.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.27 / $314.45 / $513.07
| Professional | | $267.27 | $314.45 | $513.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.14 / $410.19 / $2,120.09
| Professional | | $228.14 | $410.19 | $2,120.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $7,228.00 / $12,680.00
| Facility | | $3,599.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.83 / $413.49 / $1,498.33
| Professional | | $268.83 | $413.49 | $1,498.33 |