- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,398.83 / $2,398.83
| Facility | | $1,513.56 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $371.54 / $426.58
| Professional | | $346.74 | $371.54 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $1,122.02 / $1,258.93
| Facility | | $0.02 | $1,122.02 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $758.58
| Professional | | $602.56 | $602.56 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $316.23 / $758.58
| Professional | | $218.78 | $316.23 | $758.58 |