- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $1,543.03 / $3,955.04
| Facility | | $1,518.41 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.13 / $502.01 / $678.03
| Professional | | $491.13 | $502.01 | $678.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.11 / $596.60 / $961.54
| Professional | | $507.11 | $596.60 | $961.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $703.11 / $1,020.86
| Professional | | $350.00 | $703.11 | $1,020.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.00 / $1,788.00 / $4,602.00
| Facility | | $1,069.00 | $1,788.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $452.22 / $701.38 / $1,078.33
| Professional | | $452.22 | $701.38 | $1,078.33 |