- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $771.01 / $1,447.64 / $2,236.89
| Facility | | $771.01 | $1,447.64 | $2,236.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.41 / $525.41 / $700.56
| Professional | | $525.41 | $525.41 | $700.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.70 / $875.70 / $875.70
| Professional | | $875.70 | $875.70 | $875.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $560.45 / $700.56 / $942.47
| Facility | | $560.45 | $700.56 | $942.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.24 / $420.34 / $3,488.79
| Professional | | $294.24 | $420.34 | $3,488.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.24 / $420.34 / $1,050.83
| Professional | | $294.24 | $420.34 | $1,050.83 |