- 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
- $461.15 / $533.00 / $755.61
| Professional | | $461.15 | $533.00 | $755.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $444.75 / $607.51 / $963.35
| Professional | | $444.75 | $607.51 | $963.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $632.82 / $829.16 / $1,040.43
| Professional | | $632.82 | $829.16 | $1,040.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.06 / $724.32 / $1,092.81
| Professional | | $468.06 | $724.32 | $1,092.81 |