- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $3,981.07
| Facility | | $1,348.96 | $1,348.96 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $245.47 / $616.60
| Professional | | $151.36 | $245.47 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $177.83 / $281.84
| Professional | | $131.83 | $177.83 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $229.09 / $436.52
| Professional | | $123.03 | $229.09 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $223.87 / $354.81
| Professional | | $123.03 | $223.87 | $354.81 |