- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $169.82 / $354.81
| Professional | | $112.20 | $169.82 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $154.88 / $239.88
| Professional | | $104.71 | $154.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $199.53 / $302.00
| Professional | | $117.49 | $199.53 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $181.97 / $275.42
| Professional | | $123.03 | $181.97 | $275.42 |