- 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
- $190.55 / $331.13 / $457.09
| Professional | | $190.55 | $331.13 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $263.03 / $562.34
| Professional | | $223.87 | $263.03 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $398.11 / $588.84
| Professional | | $275.42 | $398.11 | $588.84 |
- 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
- $288.40 / $398.11 / $602.56
| Professional | | $288.40 | $398.11 | $602.56 |