- 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
- $458.13 / $518.74 / $850.08
| Professional | | $458.13 | $518.74 | $850.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.59 / $648.55 / $828.69
| Professional | | $468.59 | $648.55 | $828.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.01 / $767.52 / $1,033.73
| Professional | | $572.01 | $767.52 | $1,033.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,806.00 / $3,465.00 / $5,510.00
| Facility | | $1,806.00 | $3,465.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $388.60 / $715.10 / $995.62
| Professional | | $388.60 | $715.10 | $995.62 |