- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $380.19 / $1,412.54
| Facility | | $380.19 | $380.19 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $323.59 / $416.87
| Professional | | $213.80 | $323.59 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Professional | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $9,120.11
| Facility | | $2,884.03 | $2,884.03 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $302.00 / $436.52
| Professional | | $190.55 | $302.00 | $436.52 |