- 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
- $389.25 / $526.51 / $674.95
| Professional | | $389.25 | $526.51 | $674.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.51 / $525.25 / $867.22
| Professional | | $410.51 | $525.25 | $867.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.50 / $695.35 / $925.28
| Professional | | $549.50 | $695.35 | $925.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,417.00 / $4,915.00
| Facility | | $540.00 | $1,417.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.11 / $657.41 / $983.77
| Professional | | $381.11 | $657.41 | $983.77 |