- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,380.38 / $2,187.76
| Facility | | $1,174.90 | $1,380.38 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $912.01 / $1,584.89
| Professional | | $812.83 | $912.01 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $812.83 / $1,584.89
| Facility | | $524.81 | $812.83 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $812.83 / $1,584.89
| Facility | | $524.81 | $812.83 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Professional | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Professional | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,819.70 / $1,819.70
| Facility | | $1,318.26 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $6,309.57 / $6,309.57
| Professional | | $2,290.87 | $6,309.57 | $6,309.57 |