- 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
- $455.11 / $617.46 / $795.89
| Professional | | $455.11 | $617.46 | $795.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.68 / $612.53 / $1,018.41
| Professional | | $485.68 | $612.53 | $1,018.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.09 / $813.96 / $1,090.04
| Professional | | $658.09 | $813.96 | $1,090.04 |
- 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
- $481.82 / $769.31 / $1,139.05
| Professional | | $481.82 | $769.31 | $1,139.05 |