- 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
- $323.83 / $467.35 / $750.34
| Professional | | $323.83 | $467.35 | $750.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.24 / $490.20 / $939.77
| Professional | | $359.24 | $490.20 | $939.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.44 / $601.78 / $1,008.02
| Professional | | $466.44 | $601.78 | $1,008.02 |
- 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
- $410.92 / $701.37 / $1,085.26
| Professional | | $410.92 | $701.37 | $1,085.26 |