- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,238.72
| Facility | | $870.96 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $338.84 / $436.52
| Professional | | $223.87 | $338.84 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,754.23 / $3,715.35
| Facility | | $2,344.23 | $2,754.23 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,630.78 / $5,128.61
| Facility | | $1,096.48 | $3,630.78 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $380.19 / $562.34
| Professional | | $269.15 | $380.19 | $562.34 |