- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.77 / $758.85 / $883.15
| Professional | | $518.77 | $758.85 | $883.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.94 / $919.74 / $1,296.26
| Professional | | $772.94 | $919.74 | $1,296.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $538.05 / $860.43 / $1,651.73
| Professional | | $538.05 | $860.43 | $1,651.73 |
- 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
- $531.29 / $782.24 / $1,199.44
| Professional | | $531.29 | $782.24 | $1,199.44 |