- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $2,290.87
| Facility | | $346.74 | $346.74 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $338.84 / $426.58
| Professional | | $269.15 | $338.84 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Professional | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $22,908.68
| Facility | | $8,511.38 | $8,511.38 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $478.63 / $758.58
| Professional | | $331.13 | $478.63 | $758.58 |