- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.87 / $904.66 / $9,115.81
| Facility | | $346.87 | $904.66 | $9,115.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.37 / $137.68 / $207.49
| Professional | | $92.37 | $137.68 | $207.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.01 / $199.08 / $287.56
| Professional | | $118.01 | $199.08 | $287.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,002.57 / $1,002.57 / $1,002.57
| Facility | | $1,002.57 | $1,002.57 | $1,002.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.28 / $151.28 / $151.28
| Professional | | $151.28 | $151.28 | $151.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.56 / $211.89 / $485.44
| Professional | | $166.56 | $211.89 | $485.44 |