- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,090.30 / $3,090.30
| Facility | | $1,949.84 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $316.23 / $501.19
| Professional | | $281.84 | $316.23 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63.10 / $79.43 / $151.36
| Facility | | $63.10 | $79.43 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.13 / $275.42 / $489.78
| Facility | | $89.13 | $275.42 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $138.04
| Professional | | $109.65 | $109.65 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Professional | | $446.68 | $446.68 | $446.68 |