- 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
- $230.73 / $368.12 / $472.61
| Professional | | $230.73 | $368.12 | $472.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.38 / $445.92 / $717.42
| Professional | | $281.38 | $445.92 | $717.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.69 / $622.13 / $1,011.66
| Professional | | $386.69 | $622.13 | $1,011.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.36 / $630.97 / $907.80
| Professional | | $376.36 | $630.97 | $907.80 |