- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $3,388.44
| Facility | | $1,230.27 | $1,230.27 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $363.08 / $467.74
| Professional | | $263.03 | $363.08 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $933.25 / $2,818.38
| Facility | | $831.76 | $933.25 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $316.23 / $457.09
| Professional | | $288.40 | $316.23 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,513.56 / $2,137.96
| Facility | | $794.33 | $1,513.56 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $489.78 / $933.25
| Professional | | $489.78 | $489.78 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $489.78
| Professional | | $295.12 | $295.12 | $489.78 |