- 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
- $229.09 / $295.12 / $776.25
| Professional | | $229.09 | $295.12 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $245.47 / $416.87
| Professional | | $186.21 | $245.47 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $316.23 / $512.86
| Professional | | $89.13 | $316.23 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $316.23 / $467.74
| Professional | | $218.78 | $316.23 | $467.74 |