- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $204.17 / $549.54
| Professional | | $117.49 | $204.17 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $162.18 / $316.23
| Professional | | $138.04 | $162.18 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $251.19 / $363.08
| Professional | | $169.82 | $251.19 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $17,378.01
| Facility | | $3,715.35 | $7,762.47 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $245.47 / $371.54
| Professional | | $177.83 | $245.47 | $371.54 |