- 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
- $112.20 / $165.96 / $346.74
| Professional | | $112.20 | $165.96 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $154.88 / $223.87
| Professional | | $104.71 | $154.88 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $204.17 / $309.03
| Professional | | $95.50 | $204.17 | $309.03 |
- 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
- $112.20 / $181.97 / $269.15
| Professional | | $112.20 | $181.97 | $269.15 |