- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,706.14 / $4,029.78
| Facility | | $2,090.73 | $3,706.14 | $4,029.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.24 / $262.82 / $353.68
| Professional | | $202.24 | $262.82 | $353.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.55 / $319.36 / $426.62
| Professional | | $223.55 | $319.36 | $426.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.00 / $374.28 / $530.91
| Professional | | $174.00 | $374.28 | $530.91 |
- 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
- $205.52 / $342.80 / $568.44
| Professional | | $205.52 | $342.80 | $568.44 |