- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,056.78 / $1,056.78 / $1,056.78
| Facility | | $1,056.78 | $1,056.78 | $1,056.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.51 / $988.51 / $988.51
| Professional | | $988.51 | $988.51 | $988.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.98 / $88.11 / $133.49
| Professional | | $52.98 | $88.11 | $133.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,888.83 / $10,576.56 / $15,184.17
| Facility | | $7,888.83 | $10,576.56 | $15,184.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.96 / $275.37 / $383.02
| Professional | | $235.96 | $275.37 | $383.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.94 / $219.54 / $362.37
| Professional | | $165.94 | $219.54 | $362.37 |