- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $7,244.36
| Facility | | $3,235.94 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $794.33 / $1,621.81
| Professional | | $144.54 | $794.33 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $954.99 / $1,698.24
| Professional | | $120.23 | $954.99 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $912.01 / $1,479.11
| Professional | | $138.04 | $912.01 | $1,479.11 |