- 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
- $171.38 / $241.32 / $297.58
| Professional | | $171.38 | $241.32 | $297.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.61 / $291.56 / $343.01
| Professional | | $214.61 | $291.56 | $343.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.24 / $302.76 / $458.30
| Professional | | $193.24 | $302.76 | $458.30 |
- 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
- $202.02 / $299.04 / $490.56
| Professional | | $202.02 | $299.04 | $490.56 |