- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $151.36 / $426.58
| Professional | | $131.83 | $151.36 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $162.18 / $263.03
| Professional | | $131.83 | $162.18 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $213.80 / $309.03
| Professional | | $144.54 | $213.80 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $169.82 / $316.23
| Professional | | $120.23 | $169.82 | $316.23 |