- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,454.71 / $4,897.79
| Facility | | $1,513.56 | $2,454.71 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $120.23 / $123.03
| Professional | | $114.82 | $120.23 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $123.03 / $190.55
| Facility | | $114.82 | $123.03 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $97.72 / $123.03
| Professional | | $97.72 | $97.72 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.93 / $208.93 / $208.93
| Facility | | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Professional | | $645.65 | $645.65 | $645.65 |