- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,248.02 / $2,885.45 / $3,955.04
| Facility | | $1,248.02 | $2,885.45 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.50 / $678.91 / $763.66
| Professional | | $491.50 | $678.91 | $763.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.16 / $803.72 / $1,217.71
| Professional | | $683.16 | $803.72 | $1,217.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $876.72 / $1,327.05
| Professional | | $250.00 | $876.72 | $1,327.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $3,447.00 / $5,685.00
| Facility | | $2,569.00 | $3,447.00 | $5,685.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.14 / $665.49 / $1,422.39
| Professional | | $516.14 | $665.49 | $1,422.39 |