- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,706.14 / $5,957.21
| Facility | | $2,090.73 | $3,706.14 | $5,957.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.69 / $182.66 / $250.61
| Professional | | $162.69 | $182.66 | $250.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.09 / $269.32 / $352.18
| Professional | | $199.09 | $269.32 | $352.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.37 / $281.76 / $426.07
| Professional | | $179.37 | $281.76 | $426.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.23 / $256.81 / $387.54
| Professional | | $197.23 | $256.81 | $387.54 |