- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,706.14 / $6,839.05
| Facility | | $2,090.73 | $3,706.14 | $6,839.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.76 / $647.95 / $781.31
| Professional | | $478.76 | $647.95 | $781.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.76 / $801.09 / $1,098.43
| Professional | | $560.76 | $801.09 | $1,098.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $653.75 / $866.61 / $1,551.34
| Professional | | $653.75 | $866.61 | $1,551.34 |
- 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
- $583.57 / $851.30 / $1,432.73
| Professional | | $583.57 | $851.30 | $1,432.73 |