- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,006.67 / $2,993.72 / $3,955.04
| Facility | | $1,006.67 | $2,993.72 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.41 / $496.42 / $601.28
| Professional | | $426.41 | $496.42 | $601.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.66 / $641.32 / $837.44
| Professional | | $512.66 | $641.32 | $837.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.77 / $561.23 / $1,114.53
| Professional | | $358.77 | $561.23 | $1,114.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $4,628.00 / $7,350.00
| Facility | | $2,654.00 | $4,628.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.80 / $528.61 / $770.66
| Professional | | $415.80 | $528.61 | $770.66 |