- 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
- $381.81 / $514.27 / $724.70
| Professional | | $381.81 | $514.27 | $724.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.66 / $675.31 / $972.92
| Professional | | $493.66 | $675.31 | $972.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $595.72 / $827.50 / $1,191.28
| Professional | | $595.72 | $827.50 | $1,191.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,806.00 / $3,465.00 / $5,510.00
| Facility | | $1,806.00 | $3,465.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.08 / $712.78 / $1,278.08
| Professional | | $507.08 | $712.78 | $1,278.08 |