- 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
- $121.19 / $186.09 / $302.30
| Professional | | $121.19 | $186.09 | $302.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.33 / $204.75 / $342.34
| Professional | | $133.33 | $204.75 | $342.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.72 / $255.88 / $381.77
| Professional | | $183.72 | $255.88 | $381.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.74 / $260.87 / $424.19
| Professional | | $147.74 | $260.87 | $424.19 |