- 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
- $380.21 / $416.37 / $419.50
| Professional | | $380.21 | $416.37 | $419.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.42 / $447.55 / $715.33
| Professional | | $380.42 | $447.55 | $715.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.48 / $445.13 / $791.48
| Professional | | $300.48 | $445.13 | $791.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $3,539.00 / $6,383.00
| Facility | | $1,649.00 | $3,539.00 | $6,383.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.60 / $404.00 / $595.12
| Professional | | $280.60 | $404.00 | $595.12 |