- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,398.83
| Facility | | $1,096.48 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $93.33 / $114.82
| Professional | | $52.48 | $93.33 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,412.54 / $1,905.46
| Facility | | $1,174.90 | $1,412.54 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $177.83
| Facility | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Professional | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $588.84 / $1,548.82
| Facility | | $251.19 | $588.84 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $100.00 / $186.21
| Professional | | $75.86 | $100.00 | $186.21 |