- 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
- $117.49 / $199.53 / $371.54
| Professional | | $117.49 | $199.53 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $194.98 / $331.13
| Professional | | $123.03 | $194.98 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $251.19 / $446.68
| Professional | | $144.54 | $251.19 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,454.71 / $6,025.60
| Facility | | $1,380.38 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $208.93 / $354.81
| Professional | | $120.23 | $208.93 | $354.81 |