- 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
- $399.77 / $504.85 / $620.79
| Professional | | $399.77 | $504.85 | $620.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.37 / $574.90 / $873.95
| Professional | | $415.37 | $574.90 | $873.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.84 / $659.64 / $913.56
| Professional | | $507.84 | $659.64 | $913.56 |
- 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
- $349.76 / $578.36 / $978.97
| Professional | | $349.76 | $578.36 | $978.97 |