- 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
- $254.96 / $361.79 / $476.57
| Professional | | $254.96 | $361.79 | $476.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.72 / $483.60 / $720.51
| Professional | | $307.72 | $483.60 | $720.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.53 / $562.37 / $1,045.54
| Professional | | $367.53 | $562.37 | $1,045.54 |
- 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
- $388.06 / $541.33 / $915.27
| Professional | | $388.06 | $541.33 | $915.27 |