- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $467.74 / $8,511.38
| Facility | | $239.88 | $467.74 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $467.74 / $776.25
| Professional | | $229.09 | $467.74 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $467.74 / $1,412.54
| Facility | | $346.74 | $467.74 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,258.93 / $1,513.56
| Professional | | $741.31 | $1,258.93 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $912.01 / $1,621.81
| Professional | | $281.84 | $912.01 | $1,621.81 |