- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $371.54 / $660.69
| Professional | | $162.18 | $371.54 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $288.40 / $562.34
| Professional | | $147.91 | $288.40 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $338.84 / $812.83
| Professional | | $141.25 | $338.84 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,511.89 / $6,025.60
| Facility | | $1,380.38 | $2,511.89 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $316.23 / $758.58
| Professional | | $173.78 | $316.23 | $758.58 |