- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,778.87 / $4,216.43 / $4,764.06
| Facility | | $2,778.87 | $4,216.43 | $4,764.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.89 / $482.97 / $758.62
| Professional | | $309.89 | $482.97 | $758.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.65 / $540.26 / $914.78
| Professional | | $347.65 | $540.26 | $914.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.97 / $682.95 / $1,039.42
| Professional | | $501.97 | $682.95 | $1,039.42 |
- 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
- $479.74 / $777.77 / $1,181.89
| Professional | | $479.74 | $777.77 | $1,181.89 |