- 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
- $289.26 / $476.65 / $635.29
| Professional | | $289.26 | $476.65 | $635.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.07 / $559.67 / $888.60
| Professional | | $280.07 | $559.67 | $888.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.77 / $644.46 / $1,274.55
| Professional | | $332.77 | $644.46 | $1,274.55 |
- 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
- $509.87 / $692.11 / $1,166.31
| Professional | | $509.87 | $692.11 | $1,166.31 |