- 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
- $257.98 / $388.68 / $513.04
| Professional | | $257.98 | $388.68 | $513.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.62 / $492.08 / $780.89
| Professional | | $313.62 | $492.08 | $780.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.72 / $677.16 / $1,086.19
| Professional | | $426.72 | $677.16 | $1,086.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.91 / $678.62 / $967.94
| Professional | | $397.91 | $678.62 | $967.94 |