- 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
- $243.50 / $309.14 / $406.05
| Professional | | $243.50 | $309.14 | $406.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.37 / $404.75 / $573.41
| Professional | | $256.37 | $404.75 | $573.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.60 / $447.75 / $838.27
| Professional | | $307.60 | $447.75 | $838.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.60 / $519.09 / $767.81
| Professional | | $315.60 | $519.09 | $767.81 |