- 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
- $341.19 / $437.83 / $586.71
| Professional | | $341.19 | $437.83 | $586.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.81 / $614.22 / $843.35
| Professional | | $410.81 | $614.22 | $843.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.58 / $668.86 / $1,207.95
| Professional | | $491.58 | $668.86 | $1,207.95 |
- 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
- $372.42 / $643.49 / $1,234.76
| Professional | | $372.42 | $643.49 | $1,234.76 |