- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,120.00 / $3,706.14
| Facility | | $2,090.73 | $3,120.00 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.13 / $304.06 / $456.76
| Professional | | $222.13 | $304.06 | $456.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.25 / $368.93 / $511.93
| Professional | | $258.25 | $368.93 | $511.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.97 / $357.42 / $580.01
| Professional | | $242.97 | $357.42 | $580.01 |
- 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
- $241.30 / $402.04 / $619.67
| Professional | | $241.30 | $402.04 | $619.67 |