- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $1,412.54
| Facility | | $645.65 | $645.65 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $575.44 / $741.31
| Professional | | $223.87 | $575.44 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $776.25 / $1,148.15
| Professional | | $489.78 | $776.25 | $1,148.15 |