- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $380.19 / $891.25
| Professional | | $316.23 | $380.19 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $354.81 / $549.54
| Professional | | $263.03 | $354.81 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $407.38 / $691.83
| Professional | | $89.13 | $407.38 | $691.83 |
- 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
- $288.40 / $416.87 / $691.83
| Professional | | $288.40 | $416.87 | $691.83 |