- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,084.59 / $2,365.89 / $3,706.14
| Facility | | $1,084.59 | $2,365.89 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.71 / $488.65 / $717.94
| Professional | | $353.71 | $488.65 | $717.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.89 / $550.35 / $1,036.94
| Professional | | $400.89 | $550.35 | $1,036.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.71 / $674.45 / $1,115.49
| Professional | | $475.71 | $674.45 | $1,115.49 |
- 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
- $403.45 / $773.22 / $1,176.29
| Professional | | $403.45 | $773.22 | $1,176.29 |