- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $1,543.03 / $3,955.04
| Facility | | $1,518.41 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.45 / $157.44 / $194.89
| Professional | | $64.45 | $157.44 | $194.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.03 / $126.33 / $222.84
| Professional | | $45.03 | $126.33 | $222.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $818.76 / $818.76 / $818.76
| Facility | | $818.76 | $818.76 | $818.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.71 / $134.74 / $333.59
| Professional | | $53.71 | $134.74 | $333.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.41 / $181.55 / $332.05
| Professional | | $141.41 | $181.55 | $332.05 |