- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $151.36 / $338.84
| Professional | | $120.23 | $151.36 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $128.82 / $239.88
| Professional | | $97.72 | $128.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $199.53 / $269.15
| Professional | | $125.89 | $199.53 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $173.78 / $263.03
| Professional | | $114.82 | $173.78 | $263.03 |