- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $7,585.78 / $8,709.64
| Facility | | $1,659.59 | $7,585.78 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,288.25 / $5,248.07
| Professional | | $707.95 | $1,288.25 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $114.82
| Professional | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $758.58 / $1,949.84
| Facility | | $177.83 | $758.58 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $56.23 / $56.23
| Facility | | $56.23 | $56.23 | $56.23 |