- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,511.89 / $5,011.87
| Facility | | $1,862.09 | $2,511.89 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $234.42 / $660.69
| Professional | | $107.15 | $234.42 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $218.78 / $457.09
| Professional | | $95.50 | $218.78 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $234.42 / $660.69
| Professional | | $120.23 | $234.42 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,454.71 / $6,025.60
| Facility | | $1,348.96 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $269.15 / $831.76
| Professional | | $125.89 | $269.15 | $831.76 |