- 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
- $403.16 / $566.08 / $915.52
| Professional | | $403.16 | $566.08 | $915.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.79 / $611.63 / $1,176.49
| Professional | | $448.79 | $611.63 | $1,176.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.83 / $749.54 / $1,265.08
| Professional | | $573.83 | $749.54 | $1,265.08 |
- 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
- $454.36 / $878.04 / $1,334.60
| Professional | | $454.36 | $878.04 | $1,334.60 |