- 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
- $102.33 / $257.04 / $562.34
| Professional | | $102.33 | $257.04 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $234.42 / $446.68
| Professional | | $93.33 | $234.42 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $245.47 / $602.56
| Professional | | $125.89 | $245.47 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,412.54 / $6,456.54
| Facility | | $316.23 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $234.42 / $575.44
| Professional | | $114.82 | $234.42 | $575.44 |