- 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
- $311.43 / $386.98 / $542.26
| Professional | | $311.43 | $386.98 | $542.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.77 / $382.09 / $773.53
| Professional | | $324.77 | $382.09 | $773.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $544.09 / $653.53
| Professional | | $200.00 | $544.09 | $653.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $4,086.00 / $9,622.00
| Facility | | $3,146.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.67 / $484.19 / $636.05
| Professional | | $339.67 | $484.19 | $636.05 |