- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.14 / $829.35 / $914.66
| Professional | | $655.14 | $829.35 | $914.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.66 / $920.78 / $1,464.52
| Professional | | $782.66 | $920.78 | $1,464.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $829.93 / $992.82 / $1,808.54
| Professional | | $829.93 | $992.82 | $1,808.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,080.00 / $3,912.00 / $7,350.00
| Facility | | $2,080.00 | $3,912.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.12 / $979.75 / $1,645.86
| Professional | | $681.12 | $979.75 | $1,645.86 |