- 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
- $446.68 / $512.86 / $1,230.27
| Professional | | $446.68 | $512.86 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $537.03 / $933.25
| Professional | | $398.11 | $537.03 | $933.25 |
- 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
- $407.38 / $537.03 / $851.14
| Professional | | $407.38 | $537.03 | $851.14 |