- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $316.23 / $645.65
| Professional | | $199.53 | $316.23 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $239.88 / $363.08
| Professional | | $177.83 | $239.88 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $309.03 / $575.44
| Professional | | $165.96 | $309.03 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $302.00 / $457.09
| Professional | | $177.83 | $302.00 | $457.09 |