- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $281.84 / $724.44
| Professional | | $181.97 | $281.84 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $234.42 / $426.58
| Professional | | $177.83 | $234.42 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $380.19 / $851.14
| Professional | | $245.47 | $380.19 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $346.74 / $537.03
| Professional | | $218.78 | $346.74 | $537.03 |