- 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
- $83.01 / $389.21 / $654.97
| Professional | | $83.01 | $389.21 | $654.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.75 / $457.99 / $928.13
| Professional | | $104.75 | $457.99 | $928.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.35 / $385.58 / $1,392.56
| Professional | | $123.35 | $385.58 | $1,392.56 |
- 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
- $579.03 / $856.33 / $1,162.32
| Professional | | $579.03 | $856.33 | $1,162.32 |