- 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
- $309.14 / $426.40 / $570.21
| Professional | | $309.14 | $426.40 | $570.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.28 / $491.71 / $705.04
| Professional | | $347.28 | $491.71 | $705.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.60 / $613.39 / $1,034.32
| Professional | | $400.60 | $613.39 | $1,034.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $414.60 / $645.11 / $953.21
| Professional | | $414.60 | $645.11 | $953.21 |