- 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
- $206.75 / $319.39 / $424.83
| Professional | | $206.75 | $319.39 | $424.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.80 / $418.34 / $616.26
| Professional | | $293.80 | $418.34 | $616.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.46 / $534.40 / $888.05
| Professional | | $341.46 | $534.40 | $888.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.35 / $478.25 / $927.04
| Professional | | $334.35 | $478.25 | $927.04 |