- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $1,819.70 / $2,511.89
| Facility | | $338.84 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $281.84 / $426.58
| Professional | | $245.47 | $281.84 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Facility | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $426.58 / $524.81
| Professional | | $281.84 | $426.58 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $346.74 / $851.14
| Facility | | $128.82 | $346.74 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $331.13 / $512.86
| Professional | | $251.19 | $331.13 | $512.86 |