- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $1,698.24
| Facility | | $354.81 | $354.81 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $346.74 / $389.05
| Professional | | $245.47 | $346.74 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $588.84 / $588.84
| Facility | | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Professional | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $10,471.29
| Facility | | $2,884.03 | $2,884.03 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $426.58 / $630.96
| Professional | | $281.84 | $426.58 | $630.96 |