- 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
- $424.92 / $578.67 / $681.36
| Professional | | $424.92 | $578.67 | $681.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.09 / $617.41 / $871.49
| Professional | | $446.09 | $617.41 | $871.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.15 / $760.68 / $1,003.62
| Professional | | $643.15 | $760.68 | $1,003.62 |
- 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
- $399.05 / $695.67 / $1,065.25
| Professional | | $399.05 | $695.67 | $1,065.25 |