- 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
- $269.15 / $426.58 / $891.25
| Professional | | $269.15 | $426.58 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $398.11 / $724.44
| Professional | | $269.15 | $398.11 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $512.86 / $954.99
| Professional | | $354.81 | $512.86 | $954.99 |
- 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
- $281.84 / $467.74 / $891.25
| Professional | | $281.84 | $467.74 | $891.25 |