- 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
- $120.23 / $181.97 / $234.42
| Professional | | $120.23 | $181.97 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $2,041.74
| Facility | | $1,258.93 | $1,513.56 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,698.24 / $3,090.30
| Facility | | $645.65 | $1,698.24 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $204.17 / $316.23
| Professional | | $144.54 | $204.17 | $316.23 |