- 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
- $215.42 / $439.03 / $872.35
| Professional | | $215.42 | $439.03 | $872.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.10 / $407.26 / $614.03
| Professional | | $233.10 | $407.26 | $614.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.70 / $536.16 / $986.13
| Professional | | $310.70 | $536.16 | $986.13 |
- 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
- $420.27 / $618.96 / $1,052.72
| Professional | | $420.27 | $618.96 | $1,052.72 |