- 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
- $381.51 / $421.47 / $597.24
| Professional | | $381.51 | $421.47 | $597.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $452.87 / $635.96 / $717.40
| Professional | | $452.87 | $635.96 | $717.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.72 / $521.54 / $1,084.43
| Professional | | $315.72 | $521.54 | $1,084.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $4,628.00 / $7,350.00
| Facility | | $2,654.00 | $4,628.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.10 / $541.70 / $901.81
| Professional | | $357.10 | $541.70 | $901.81 |