- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,073.15 / $3,937.50 / $3,937.50
| Facility | | $2,073.15 | $3,937.50 | $3,937.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.07 / $457.41 / $719.74
| Professional | | $292.07 | $457.41 | $719.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.39 / $514.88 / $872.04
| Professional | | $327.39 | $514.88 | $872.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.02 / $651.32 / $1,047.51
| Professional | | $474.02 | $651.32 | $1,047.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.81 / $668.03 / $1,037.71
| Professional | | $363.81 | $668.03 | $1,037.71 |