- 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
- $144.54 / $186.21 / $380.19
| Professional | | $144.54 | $186.21 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $190.55 / $257.04
| Professional | | $138.04 | $190.55 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $223.87 / $371.54
| Professional | | $151.36 | $223.87 | $371.54 |
- 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
- $147.91 / $204.17 / $331.13
| Professional | | $147.91 | $204.17 | $331.13 |