- 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
- $476.48 / $650.75 / $750.04
| Professional | | $476.48 | $650.75 | $750.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.19 / $638.33 / $983.27
| Professional | | $461.19 | $638.33 | $983.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $659.05 / $803.43 / $1,071.05
| Professional | | $659.05 | $803.43 | $1,071.05 |
- 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
- $456.26 / $742.42 / $1,115.39
| Professional | | $456.26 | $742.42 | $1,115.39 |