- 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
- $440.12 / $642.80 / $858.40
| Professional | | $440.12 | $642.80 | $858.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.26 / $883.30 / $1,101.61
| Professional | | $658.26 | $883.30 | $1,101.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.64 / $759.10 / $1,541.34
| Professional | | $461.64 | $759.10 | $1,541.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $4,628.00 / $7,350.00
| Facility | | $2,654.00 | $4,628.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.72 / $770.87 / $1,172.38
| Professional | | $536.72 | $770.87 | $1,172.38 |