- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,412.54 / $4,897.79
| Facility | | $758.58 | $1,412.54 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $223.87 / $691.83
| Professional | | $83.18 | $223.87 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $173.78 / $363.08
| Professional | | $77.62 | $173.78 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $239.88 / $549.54
| Professional | | $107.15 | $239.88 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,454.71 / $6,025.60
| Facility | | $1,380.38 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $263.03 / $489.78
| Professional | | $102.33 | $263.03 | $489.78 |