- 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
- $303.61 / $466.32 / $740.02
| Professional | | $303.61 | $466.32 | $740.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.47 / $535.70 / $911.20
| Professional | | $340.47 | $535.70 | $911.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.55 / $674.59 / $1,011.92
| Professional | | $437.55 | $674.59 | $1,011.92 |
- 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
- $375.37 / $743.71 / $1,061.58
| Professional | | $375.37 | $743.71 | $1,061.58 |