- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $744.38 / $1,397.65 / $2,159.65
| Facility | | $744.38 | $1,397.65 | $2,159.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.37 / $689.90 / $689.90
| Professional | | $287.37 | $689.90 | $689.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $597.91 / $1,107.89 / $1,533.71
| Facility | | $597.91 | $1,107.89 | $1,533.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $541.10 / $676.37 / $909.93
| Facility | | $541.10 | $676.37 | $909.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.08 / $405.82 / $3,381.85
| Professional | | $284.08 | $405.82 | $3,381.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.08 / $405.82 / $1,014.56
| Professional | | $284.08 | $405.82 | $1,014.56 |