- 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
- $464.94 / $643.10 / $750.70
| Professional | | $464.94 | $643.10 | $750.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.69 / $619.63 / $958.59
| Professional | | $447.69 | $619.63 | $958.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.45 / $794.88 / $1,040.32
| Professional | | $645.45 | $794.88 | $1,040.32 |
- 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
- $426.71 / $633.41 / $1,053.25
| Professional | | $426.71 | $633.41 | $1,053.25 |