- 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
- $128.82 / $169.82 / $389.05
| Professional | | $128.82 | $169.82 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $134.90 / $239.88
| Professional | | $102.33 | $134.90 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $204.17 / $281.84
| Professional | | $89.13 | $204.17 | $281.84 |
- 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 / $177.83 / $263.03
| Professional | | $112.20 | $177.83 | $263.03 |