- 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
- $162.18 / $234.42 / $588.84
| Professional | | $162.18 | $234.42 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $208.93 / $363.08
| Professional | | $158.49 | $208.93 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $295.12 / $426.58
| Professional | | $151.36 | $295.12 | $426.58 |
- 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
- $169.82 / $263.03 / $446.68
| Professional | | $169.82 | $263.03 | $446.68 |