- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $2,041.74 / $2,187.76
| Facility | | $316.23 | $2,041.74 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $478.63
| Professional | | $316.23 | $316.23 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,513.56 / $2,570.40
| Facility | | $851.14 | $1,513.56 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,174.90 / $1,698.24
| Facility | | $316.23 | $1,174.90 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $426.58 / $707.95
| Facility | | $316.23 | $426.58 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,479.11 / $2,238.72
| Facility | | $371.54 | $1,479.11 | $2,238.72 |