- 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
- $503.13 / $548.91 / $556.46
| Professional | | $503.13 | $548.91 | $556.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.49 / $591.16 / $959.37
| Professional | | $502.49 | $591.16 | $959.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.74 / $582.51 / $1,046.42
| Professional | | $392.74 | $582.51 | $1,046.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $4,628.00 / $8,439.20
| Facility | | $2,654.00 | $4,628.00 | $8,439.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.40 / $500.94 / $781.74
| Professional | | $400.40 | $500.94 | $781.74 |