- 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
- $111.97 / $185.97 / $255.57
| Professional | | $111.97 | $185.97 | $255.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.69 / $245.54 / $344.39
| Professional | | $155.69 | $245.54 | $344.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.65 / $257.86 / $421.74
| Professional | | $160.65 | $257.86 | $421.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.32 / $292.33 / $453.66
| Professional | | $186.32 | $292.33 | $453.66 |