- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.33 / $847.80 / $2,680.41
| Facility | | $289.33 | $847.80 | $2,680.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.27 / $345.26 / $434.00
| Professional | | $256.27 | $345.26 | $434.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $440.51 / $440.51 / $440.51
| Facility | | $440.51 | $440.51 | $440.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.51 / $440.51 / $440.51
| Professional | | $440.51 | $440.51 | $440.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $958.10 / $2,474.44 / $2,564.67
| Facility | | $958.10 | $2,474.44 | $2,564.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,033.62 / $3,033.62 / $4,217.63
| Professional | | $3,033.62 | $3,033.62 | $4,217.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.71 / $520.75 / $520.75
| Professional | | $494.71 | $520.75 | $520.75 |