- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,981.07 / $6,165.95
| Facility | | $1,513.56 | $3,981.07 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $128.82 / $389.05
| Professional | | $63.10 | $128.82 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $77.62 / $125.89
| Professional | | $57.54 | $77.62 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $114.82 / $186.21
| Professional | | $79.43 | $114.82 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,412.54 / $6,456.54
| Facility | | $416.87 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $102.33 / $169.82
| Professional | | $58.88 | $102.33 | $169.82 |