- 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
- $173.78 / $245.47 / $588.84
| Professional | | $173.78 | $245.47 | $588.84 |
- 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
- $208.93 / $316.23 / $446.68
| Professional | | $208.93 | $316.23 | $446.68 |
- 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
- $173.78 / $251.19 / $436.52
| Professional | | $173.78 | $251.19 | $436.52 |