- 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
- $323.59 / $436.52 / $912.01
| Professional | | $323.59 | $436.52 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $407.38 / $741.31
| Professional | | $295.12 | $407.38 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $575.44 / $912.01
| Professional | | $389.05 | $575.44 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,244.36 / $13,182.57
| Facility | | $3,235.94 | $7,244.36 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $467.74 / $812.83
| Professional | | $302.00 | $467.74 | $812.83 |