- 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
- $114.82 / $134.90 / $436.52
| Professional | | $114.82 | $134.90 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $151.36 / $245.47
| Professional | | $128.82 | $151.36 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $190.55 / $275.42
| Professional | | $147.91 | $190.55 | $275.42 |
- 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
- $117.49 / $165.96 / $331.13
| Professional | | $117.49 | $165.96 | $331.13 |