- 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
- $313.22 / $424.76 / $486.23
| Professional | | $313.22 | $424.76 | $486.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.16 / $419.60 / $639.98
| Professional | | $303.16 | $419.60 | $639.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.09 / $526.49 / $697.57
| Professional | | $437.09 | $526.49 | $697.57 |
- 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
- $292.77 / $483.53 / $726.00
| Professional | | $292.77 | $483.53 | $726.00 |