- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,149.83 / $2,149.83 / $2,149.83
| Facility | | $2,149.83 | $2,149.83 | $2,149.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.61 / $135.61 / $135.61
| Professional | | $135.61 | $135.61 | $135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.47 / $1,350.47 / $1,350.47
| Facility | | $1,350.47 | $1,350.47 | $1,350.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.40 / $923.40 / $923.40
| Professional | | $923.40 | $923.40 | $923.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $593.54 / $7,638.21 / $16,463.55
| Facility | | $593.54 | $7,638.21 | $16,463.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $564.04 / $564.04 / $564.04
| Facility | | $564.04 | $564.04 | $564.04 |