- 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
- $428.41 / $560.82 / $707.90
| Professional | | $428.41 | $560.82 | $707.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.79 / $752.92 / $1,052.01
| Professional | | $533.79 | $752.92 | $1,052.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $632.83 / $816.13 / $1,484.18
| Professional | | $632.83 | $816.13 | $1,484.18 |
- 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
- $555.03 / $921.04 / $1,240.89
| Professional | | $555.03 | $921.04 | $1,240.89 |