- 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
- $200.03 / $233.61 / $313.48
| Professional | | $200.03 | $233.61 | $313.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.17 / $338.04 / $397.69
| Professional | | $240.17 | $338.04 | $397.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.04 / $339.75 / $520.77
| Professional | | $220.04 | $339.75 | $520.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.40 / $353.28 / $557.41
| Professional | | $222.40 | $353.28 | $557.41 |