- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $363.08 / $645.65
| Professional | | $165.96 | $363.08 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $512.86 / $575.44
| Professional | | $436.52 | $512.86 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $363.08 / $512.86
| Professional | | $275.42 | $363.08 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,318.26 / $5,370.32
| Facility | | $1,288.25 | $1,318.26 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $416.87 / $831.76
| Professional | | $309.03 | $416.87 | $831.76 |