- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $584.90 / $1,070.36 / $1,187.34
| Facility | | $584.90 | $1,070.36 | $1,187.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.07 / $1,070.36 / $1,187.34
| Professional | | $462.07 | $1,070.36 | $1,187.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $760.37 / $789.62 / $789.62
| Facility | | $760.37 | $789.62 | $789.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.41 / $1,156.41 / $1,156.41
| Professional | | $1,156.41 | $1,156.41 | $1,156.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $399.20 / $443.68
| Facility | | $380.19 | $399.20 | $443.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.66 / $350.94 / $998.41
| Professional | | $245.66 | $350.94 | $998.41 |