- 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
- $407.38 / $562.34 / $831.76
| Professional | | $407.38 | $562.34 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $851.14 / $1,445.44
| Professional | | $346.74 | $851.14 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $6,025.60 / $13,182.57
| Facility | | $1,230.27 | $6,025.60 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $676.08 / $1,513.56
| Professional | | $407.38 | $676.08 | $1,513.56 |