- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.94 / $805.13 / $930.18
| Professional | | $576.94 | $805.13 | $930.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $551.01 / $762.65 / $1,194.63
| Professional | | $551.01 | $762.65 | $1,194.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.43 / $998.88 / $1,292.36
| Professional | | $794.43 | $998.88 | $1,292.36 |
- 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
- $570.95 / $806.05 / $1,380.95
| Professional | | $570.95 | $806.05 | $1,380.95 |