- 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
- $131.83 / $257.04 / $512.86
| Professional | | $131.83 | $257.04 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $223.87 / $371.54
| Professional | | $120.23 | $223.87 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $281.84 / $562.34
| Professional | | $158.49 | $281.84 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $251.19 / $478.63
| Professional | | $147.91 | $251.19 | $478.63 |