- 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
- $536.17 / $736.75 / $863.42
| Professional | | $536.17 | $736.75 | $863.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.66 / $708.18 / $1,110.06
| Professional | | $511.66 | $708.18 | $1,110.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.69 / $917.54 / $1,187.96
| Professional | | $737.69 | $917.54 | $1,187.96 |
- 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
- $524.83 / $740.94 / $1,259.23
| Professional | | $524.83 | $740.94 | $1,259.23 |