- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,265.80 / $4,677.35
| Facility | | $1,513.56 | $4,265.80 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $204.17 / $416.87
| Professional | | $107.15 | $204.17 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $131.83 / $208.93
| Professional | | $93.33 | $131.83 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $213.80 / $363.08
| Professional | | $147.91 | $213.80 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $173.78 / $309.03
| Professional | | $104.71 | $173.78 | $309.03 |