- 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
- $478.86 / $669.66 / $777.04
| Professional | | $478.86 | $669.66 | $777.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.52 / $637.40 / $988.57
| Professional | | $460.52 | $637.40 | $988.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.97 / $1,063.23 / $1,107.96
| Professional | | $663.97 | $1,063.23 | $1,107.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,164.00 / $9,622.00
| Facility | | $2,838.00 | $5,164.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.86 / $758.49 / $1,121.42
| Professional | | $486.86 | $758.49 | $1,121.42 |