- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $204.17 / $489.78
| Professional | | $147.91 | $204.17 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $177.83 / $323.59
| Professional | | $158.49 | $177.83 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $281.84 / $346.74
| Professional | | $190.55 | $281.84 | $346.74 |
- 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
- $154.88 / $229.09 / $389.05
| Professional | | $154.88 | $229.09 | $389.05 |