- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.49 / $650.70 / $942.61
| Professional | | $536.49 | $650.70 | $942.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $522.91 / $723.75 / $1,251.73
| Professional | | $522.91 | $723.75 | $1,251.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $723.75 / $860.38 / $1,195.67
| Professional | | $723.75 | $860.38 | $1,195.67 |
- 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
- $503.12 / $813.92 / $1,283.34
| Professional | | $503.12 | $813.92 | $1,283.34 |