- 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
- $190.55 / $281.84 / $630.96
| Professional | | $190.55 | $281.84 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $316.23 / $457.09
| Professional | | $213.80 | $316.23 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $346.74 / $691.83
| Professional | | $151.36 | $346.74 | $691.83 |
- 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
- $194.98 / $302.00 / $562.34
| Professional | | $194.98 | $302.00 | $562.34 |