- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,973.53 / $2,993.72 / $3,955.04
| Facility | | $1,973.53 | $2,993.72 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.62 / $520.80 / $721.78
| Professional | | $356.62 | $520.80 | $721.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.98 / $765.80 / $901.94
| Professional | | $541.98 | $765.80 | $901.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.72 / $638.13 / $1,318.54
| Professional | | $377.72 | $638.13 | $1,318.54 |
- 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
- $460.60 / $651.04 / $985.70
| Professional | | $460.60 | $651.04 | $985.70 |