- 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
- $361.03 / $503.34 / $626.21
| Professional | | $361.03 | $503.34 | $626.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $423.65 / $600.63 / $817.84
| Professional | | $423.65 | $600.63 | $817.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.02 / $728.23 / $1,024.71
| Professional | | $498.02 | $728.23 | $1,024.71 |
- 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
- $410.55 / $612.82 / $1,099.32
| Professional | | $410.55 | $612.82 | $1,099.32 |