- 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
- $134.90 / $181.97 / $436.52
| Professional | | $134.90 | $181.97 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $173.78 / $281.84
| Professional | | $134.90 | $173.78 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $239.88 / $338.84
| Professional | | $158.49 | $239.88 | $338.84 |
- 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
- $128.82 / $190.55 / $331.13
| Professional | | $128.82 | $190.55 | $331.13 |