- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $7,762.47 / $7,762.47
| Facility | | $2,089.30 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $436.52
| Professional | | $177.83 | $177.83 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.39 / $48.98 / $79.43
| Facility | | $22.39 | $48.98 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.12 / $60.26 / $85.11
| Professional | | $9.12 | $60.26 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $1,096.48 / $1,412.54
| Facility | | $229.09 | $1,096.48 | $1,412.54 |