- 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
- $368.77 / $523.33 / $641.41
| Professional | | $368.77 | $523.33 | $641.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.08 / $605.48 / $843.66
| Professional | | $428.08 | $605.48 | $843.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.66 / $745.03 / $1,061.35
| Professional | | $518.66 | $745.03 | $1,061.35 |
- 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
- $416.29 / $637.84 / $1,139.70
| Professional | | $416.29 | $637.84 | $1,139.70 |