- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.01 / $557.10 / $870.84
| Professional | | $384.01 | $557.10 | $870.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.61 / $575.60 / $1,109.78
| Professional | | $418.61 | $575.60 | $1,109.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $539.29 / $795.52 / $1,175.15
| Professional | | $539.29 | $795.52 | $1,175.15 |
- 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
- $514.82 / $702.51 / $1,276.33
| Professional | | $514.82 | $702.51 | $1,276.33 |