- 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
- $128.79 / $134.47 / $187.67
| Professional | | $128.79 | $134.47 | $187.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.34 / $160.40 / $267.25
| Professional | | $136.34 | $160.40 | $267.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.90 / $206.33 / $275.27
| Professional | | $133.90 | $206.33 | $275.27 |
- 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
- $120.23 / $188.64 / $264.33
| Professional | | $120.23 | $188.64 | $264.33 |