- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $416.87 / $1,698.24
| Facility | | $416.87 | $416.87 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $407.38 / $457.09
| Professional | | $281.84 | $407.38 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Facility | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Professional | | $1,949.84 | $1,949.84 | $1,949.84 |
- 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
- $323.59 / $501.19 / $741.31
| Professional | | $323.59 | $501.19 | $741.31 |