- 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
- $190.55 / $234.42 / $575.44
| Professional | | $190.55 | $234.42 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $213.80 / $380.19
| Professional | | $162.18 | $213.80 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $288.40 / $446.68
| Professional | | $151.36 | $288.40 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $7,585.78
| Facility | | $2,570.40 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $275.42 / $416.87
| Professional | | $194.98 | $275.42 | $416.87 |