- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $169.82 / $436.52
| Professional | | $89.13 | $169.82 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $131.83 / $257.04
| Professional | | $112.20 | $131.83 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $213.80 / $309.03
| Professional | | $114.82 | $213.80 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $13,489.63
| Facility | | $3,715.35 | $7,762.47 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $194.98 / $295.12
| Professional | | $141.25 | $194.98 | $295.12 |