- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $407.38 / $977.24
| Professional | | $281.84 | $407.38 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $371.54 / $691.83
| Professional | | $275.42 | $371.54 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $524.81 / $831.76
| Professional | | $363.08 | $524.81 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $426.58 / $776.25
| Professional | | $275.42 | $426.58 | $776.25 |