- 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
- $139.04 / $159.93 / $303.39
| Professional | | $139.04 | $159.93 | $303.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.69 / $271.77 / $316.55
| Professional | | $163.69 | $271.77 | $316.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.88 / $246.08 / $551.46
| Professional | | $112.88 | $246.08 | $551.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,052.00 / $5,510.00
| Facility | | $1,812.00 | $4,052.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.67 / $343.94 / $416.38
| Professional | | $194.67 | $343.94 | $416.38 |