- 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
- $269.15 / $354.81 / $562.34
| Professional | | $269.15 | $354.81 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $457.09 / $691.83
| Professional | | $181.97 | $457.09 | $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 / $426.58 / $707.95
| Professional | | $288.40 | $426.58 | $707.95 |