- 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
- $421.34 / $605.37 / $676.55
| Professional | | $421.34 | $605.37 | $676.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.50 / $579.23 / $817.76
| Professional | | $418.50 | $579.23 | $817.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $603.36 / $757.78 / $958.48
| Professional | | $603.36 | $757.78 | $958.48 |
- 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
- $368.86 / $664.38 / $1,024.27
| Professional | | $368.86 | $664.38 | $1,024.27 |