- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $288.40 / $812.83
| Professional | | $177.83 | $288.40 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $223.87 / $371.54
| Professional | | $177.83 | $223.87 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $309.03 / $501.19
| Professional | | $199.53 | $309.03 | $501.19 |
- 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
- $190.55 / $309.03 / $478.63
| Professional | | $190.55 | $309.03 | $478.63 |