- 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
- $546.59 / $752.85 / $800.52
| Professional | | $546.59 | $752.85 | $800.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.56 / $805.37 / $1,352.92
| Professional | | $684.56 | $805.37 | $1,352.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $539.12 / $795.84 / $1,415.10
| Professional | | $539.12 | $795.84 | $1,415.10 |
- 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
- $484.84 / $680.88 / $1,069.14
| Professional | | $484.84 | $680.88 | $1,069.14 |