- 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
- $213.80 / $295.12 / $707.95
| Professional | | $213.80 | $295.12 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $257.04 / $489.78
| Professional | | $223.87 | $257.04 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $416.87 / $524.81
| Professional | | $269.15 | $416.87 | $524.81 |
- 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
- $223.87 / $338.84 / $549.54
| Professional | | $223.87 | $338.84 | $549.54 |