- 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
- $158.49 / $204.17 / $524.81
| Professional | | $158.49 | $204.17 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $208.93 / $354.81
| Professional | | $158.49 | $208.93 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $295.12 / $398.11
| Professional | | $186.21 | $295.12 | $398.11 |
- 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
- $158.49 / $239.88 / $407.38
| Professional | | $158.49 | $239.88 | $407.38 |