- 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
- $398.37 / $566.35 / $895.42
| Professional | | $398.37 | $566.35 | $895.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $442.14 / $595.72 / $1,152.43
| Professional | | $442.14 | $595.72 | $1,152.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.45 / $730.05 / $1,220.82
| Professional | | $541.45 | $730.05 | $1,220.82 |
- 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
- $460.44 / $846.23 / $1,307.29
| Professional | | $460.44 | $846.23 | $1,307.29 |