- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $147.91 / $363.08
| Professional | | $104.71 | $147.91 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $125.89 / $204.17
| Professional | | $87.10 | $125.89 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $194.98 / $338.84
| Professional | | $123.03 | $194.98 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,454.71 / $6,025.60
| Facility | | $1,380.38 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $173.78 / $295.12
| Professional | | $104.71 | $173.78 | $295.12 |