- 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
- $284.80 / $431.50 / $519.47
| Professional | | $284.80 | $431.50 | $519.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $366.40 / $495.09 / $783.88
| Professional | | $366.40 | $495.09 | $783.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $429.32 / $679.76 / $1,110.34
| Professional | | $429.32 | $679.76 | $1,110.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.51 / $592.32 / $1,176.99
| Professional | | $403.51 | $592.32 | $1,176.99 |