- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,084.60 / $2,778.87 / $3,955.04
| Facility | | $1,084.60 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.18 / $394.58 / $621.25
| Professional | | $250.18 | $394.58 | $621.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.64 / $417.42 / $728.62
| Professional | | $280.64 | $417.42 | $728.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.29 / $478.84 / $852.65
| Professional | | $384.29 | $478.84 | $852.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.13 / $490.55 / $841.96
| Professional | | $328.13 | $490.55 | $841.96 |