- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $839.74 / $1,190.84 / $2,864.75
| Facility | | $839.74 | $1,190.84 | $2,864.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.86 / $373.88 / $474.82
| Professional | | $162.86 | $373.88 | $474.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $682.65 / $1,088.72 / $2,255.71
| Facility | | $682.65 | $1,088.72 | $2,255.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.25 / $225.75 / $373.88
| Professional | | $161.25 | $225.75 | $373.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $472.25 / $472.25 / $472.25
| Facility | | $472.25 | $472.25 | $472.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.09 / $2,025.09 / $2,025.09
| Professional | | $2,025.09 | $2,025.09 | $2,025.09 |