- 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
- $330.51 / $462.17 / $587.87
| Professional | | $330.51 | $462.17 | $587.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $405.22 / $503.18 / $748.49
| Professional | | $405.22 | $503.18 | $748.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.66 / $630.12 / $810.32
| Professional | | $548.66 | $630.12 | $810.32 |
- 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
- $345.49 / $553.91 / $855.69
| Professional | | $345.49 | $553.91 | $855.69 |