- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $2,207.87 / $3,955.04
| Facility | | $1,518.41 | $2,207.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.10 / $410.64 / $649.12
| Professional | | $225.10 | $410.64 | $649.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.16 / $457.38 / $669.15
| Professional | | $253.16 | $457.38 | $669.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.64 / $471.16 / $816.10
| Professional | | $306.64 | $471.16 | $816.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.45 / $616.04 / $983.48
| Professional | | $365.45 | $616.04 | $983.48 |