- 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
- $496.27 / $557.05 / $790.18
| Professional | | $496.27 | $557.05 | $790.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.27 / $819.79 / $957.69
| Professional | | $584.27 | $819.79 | $957.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.18 / $713.41 / $1,438.89
| Professional | | $411.18 | $713.41 | $1,438.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,052.00 / $5,510.00
| Facility | | $1,812.00 | $4,052.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $452.05 / $719.63 / $1,102.20
| Professional | | $452.05 | $719.63 | $1,102.20 |