- 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
- $600.67 / $613.62 / $809.65
| Professional | | $600.67 | $613.62 | $809.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $629.38 / $740.45 / $1,161.02
| Professional | | $629.38 | $740.45 | $1,161.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $810.51 / $1,232.96
| Professional | | $300.00 | $810.51 | $1,232.96 |
- 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
- $600.69 / $851.30 / $1,310.97
| Professional | | $600.69 | $851.30 | $1,310.97 |