- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $436.52 / $912.01
| Professional | | $302.00 | $436.52 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $363.08 / $602.56
| Professional | | $275.42 | $363.08 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $575.44 / $977.24
| Professional | | $363.08 | $575.44 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $489.78 / $870.96
| Professional | | $295.12 | $489.78 | $870.96 |