- 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
- $173.95 / $290.63 / $335.74
| Professional | | $173.95 | $290.63 | $335.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.62 / $308.95 / $503.63
| Professional | | $262.62 | $308.95 | $503.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.02 / $378.88 / $732.48
| Professional | | $198.02 | $378.88 | $732.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.00 / $1,788.00 / $4,602.00
| Facility | | $1,069.00 | $1,788.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.03 / $310.39 / $529.82
| Professional | | $234.03 | $310.39 | $529.82 |