- 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
- $120.23 / $177.83 / $389.05
| Professional | | $120.23 | $177.83 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $158.49 / $288.40
| Professional | | $120.23 | $158.49 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $234.42 / $363.08
| Professional | | $158.49 | $234.42 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $194.98 / $338.84
| Professional | | $125.89 | $194.98 | $338.84 |