- 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
- $93.33 / $138.04 / $346.74
| Professional | | $93.33 | $138.04 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $125.89 / $223.87
| Professional | | $89.13 | $125.89 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $186.21 / $281.84
| Professional | | $117.49 | $186.21 | $281.84 |
- 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
- $95.50 / $147.91 / $257.04
| Professional | | $95.50 | $147.91 | $257.04 |