- 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
- $257.04 / $323.59 / $933.25
| Professional | | $257.04 | $323.59 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $323.59 / $562.34
| Professional | | $257.04 | $323.59 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $467.74 / $660.69
| Professional | | $309.03 | $467.74 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $7,585.78
| Facility | | $2,570.40 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $389.05 / $630.96
| Professional | | $257.04 | $389.05 | $630.96 |