- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,897.79 / $8,511.38
| Facility | | $1,778.28 | $4,897.79 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $1,380.38
| Professional | | $660.69 | $660.69 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.80 / $3.80 / $3.80
| Professional | | $3.80 | $3.80 | $3.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,380.38 / $3,235.94
| Facility | | $660.69 | $1,380.38 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,230.27 / $3,019.95
| Facility | | $1,071.52 | $1,230.27 | $3,019.95 |