- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,466.84 / $4,466.84
| Facility | | $1,778.28 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $257.04 / $588.84
| Professional | | $213.80 | $257.04 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $436.52 / $512.86
| Professional | | $398.11 | $436.52 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $331.13 / $407.38
| Professional | | $269.15 | $331.13 | $407.38 |