- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $239.88 / $467.74
| Professional | | $109.65 | $239.88 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $446.68 / $812.83
| Professional | | $234.42 | $446.68 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $281.84 / $562.34
| Professional | | $162.18 | $281.84 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $794.33 / $3,235.94
| Facility | | $676.08 | $794.33 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $389.05 / $758.58
| Professional | | $194.98 | $389.05 | $758.58 |