- 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
- $234.42 / $380.19 / $776.25
| Professional | | $234.42 | $380.19 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $346.74 / $645.65
| Professional | | $229.09 | $346.74 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $457.09 / $831.76
| Professional | | $302.00 | $457.09 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $389.05 / $758.58
| Professional | | $257.04 | $389.05 | $758.58 |