- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $891.25 / $2,570.40
| Professional | | $758.58 | $891.25 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $891.25 / $1,445.44
| Professional | | $794.33 | $891.25 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,318.26 / $1,778.28
| Professional | | $1,000.00 | $1,318.26 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,071.52 / $1,949.84
| Professional | | $724.44 | $1,071.52 | $1,949.84 |