- 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 / $218.78 / $436.52
| Professional | | $114.82 | $218.78 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $186.21 / $323.59
| Professional | | $107.15 | $186.21 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $257.04 / $446.68
| Professional | | $144.54 | $257.04 | $446.68 |
- 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
- $125.89 / $213.80 / $363.08
| Professional | | $125.89 | $213.80 | $363.08 |