- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,249.75 / $1,249.75 / $4,418.29
| Facility | | $1,249.75 | $1,249.75 | $4,418.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.12 / $1,262.36 / $1,262.36
| Professional | | $776.12 | $1,262.36 | $1,262.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.83 / $794.83 / $794.83
| Professional | | $794.83 | $794.83 | $794.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,805.19 / $1,805.19 / $1,805.19
| Facility | | $1,805.19 | $1,805.19 | $1,805.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,805.19 / $1,805.19 / $1,805.19
| Facility | | $1,805.19 | $1,805.19 | $1,805.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.83 / $794.83 / $794.83
| Professional | | $794.83 | $794.83 | $794.83 |