- 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
- $490.63 / $540.66 / $569.76
| Professional | | $490.63 | $540.66 | $569.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $490.84 / $577.46 / $969.59
| Professional | | $490.84 | $577.46 | $969.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.15 / $573.74 / $1,022.43
| Professional | | $387.15 | $573.74 | $1,022.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $5,164.00 / $9,622.00
| Facility | | $3,146.00 | $5,164.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.73 / $493.34 / $768.23
| Professional | | $348.73 | $493.34 | $768.23 |