- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $7,244.36
| Facility | | $3,235.94 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $812.83 / $1,778.28
| Professional | | $645.65 | $812.83 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $776.25 / $1,380.38
| Professional | | $549.54 | $776.25 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $1,318.26
| Facility | | $100.00 | $100.00 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $707.95 / $1,148.15
| Professional | | $537.03 | $707.95 | $1,148.15 |