- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.79 / $416.79 / $611.30
| Professional | | $183.79 | $416.79 | $611.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.40 / $486.88 / $969.98
| Professional | | $243.40 | $486.88 | $969.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.51 / $526.74 / $1,035.43
| Professional | | $330.51 | $526.74 | $1,035.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $4,571.00 / $7,350.00
| Facility | | $2,654.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.31 / $708.93 / $923.94
| Professional | | $510.31 | $708.93 | $923.94 |