- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $251.19 / $346.74
| Professional | | $134.90 | $251.19 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $199.53 / $407.38
| Professional | | $169.82 | $199.53 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $309.03 / $446.68
| Professional | | $213.80 | $309.03 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $288.40 / $457.09
| Professional | | $218.78 | $288.40 | $457.09 |