- 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
- $93.33 / $177.83 / $501.19
| Professional | | $93.33 | $177.83 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $151.36 / $288.40
| Professional | | $85.11 | $151.36 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $275.42 / $512.86
| Professional | | $117.49 | $275.42 | $512.86 |
- 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
- $154.88 / $269.15 / $524.81
| Professional | | $154.88 | $269.15 | $524.81 |