- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,706.14 / $5,268.14
| Facility | | $2,424.15 | $3,706.14 | $5,268.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $442.08 / $616.64 / $645.62
| Professional | | $442.08 | $616.64 | $645.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.13 / $662.51 / $1,106.84
| Professional | | $563.13 | $662.51 | $1,106.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.63 / $653.19 / $1,163.93
| Professional | | $441.63 | $653.19 | $1,163.93 |
- 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
- $397.56 / $568.98 / $879.03
| Professional | | $397.56 | $568.98 | $879.03 |