- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,288.25 / $3,890.45
| Facility | | $501.19 | $1,288.25 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $177.83 / $295.12
| Professional | | $104.71 | $177.83 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,479.11 / $1,995.26
| Facility | | $794.33 | $1,479.11 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $398.11
| Facility | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $1,096.48 / $2,344.23
| Facility | | $338.84 | $1,096.48 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $199.53 / $389.05
| Professional | | $151.36 | $199.53 | $389.05 |