- 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
- $191.53 / $244.67 / $377.53
| Professional | | $191.53 | $244.67 | $377.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.09 / $272.01 / $483.09
| Professional | | $203.09 | $272.01 | $483.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.76 / $358.16 / $473.22
| Professional | | $256.76 | $358.16 | $473.22 |
- 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
- $209.23 / $345.56 / $544.96
| Professional | | $209.23 | $345.56 | $544.96 |