- 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
- $426.58 / $501.19 / $1,174.90
| Professional | | $426.58 | $501.19 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $512.86 / $891.25
| Professional | | $389.05 | $512.86 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $501.19
| Facility | | $144.54 | $144.54 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $501.19 / $831.76
| Professional | | $389.05 | $501.19 | $831.76 |