- 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
- $310.49 / $421.05 / $641.21
| Professional | | $310.49 | $421.05 | $641.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.68 / $421.70 / $899.31
| Professional | | $304.68 | $421.70 | $899.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.70 / $561.72 / $718.23
| Professional | | $421.70 | $561.72 | $718.23 |
- 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
- $269.43 / $482.40 / $771.83
| Professional | | $269.43 | $482.40 | $771.83 |