- 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 / $173.78 / $436.52
| Professional | | $120.23 | $173.78 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $158.49 / $275.42
| Professional | | $117.49 | $158.49 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $251.19 / $398.11
| Professional | | $117.49 | $251.19 | $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
- $141.25 / $199.53 / $338.84
| Professional | | $141.25 | $199.53 | $338.84 |