- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $431.64 / $863.39 / $1,964.15
| Facility | | $431.64 | $863.39 | $1,964.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.74 / $317.60 / $317.60
| Professional | | $207.74 | $317.60 | $317.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,940.71 / $3,034.83 / $4,722.57
| Facility | | $1,940.71 | $3,034.83 | $4,722.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.76 / $116.76 / $116.76
| Professional | | $116.76 | $116.76 | $116.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.72 / $317.60 / $427.61
| Facility | | $301.72 | $317.60 | $427.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.53 / $329.53 / $329.53
| Professional | | $329.53 | $329.53 | $329.53 |