- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,659.59 / $2,454.71
| Facility | | $870.96 | $1,659.59 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $190.55 / $295.12
| Professional | | $114.82 | $190.55 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,137.96
| Facility | | $1,548.82 | $1,548.82 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,445.44 / $4,365.16
| Facility | | $602.56 | $1,445.44 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $199.53 / $380.19
| Professional | | $158.49 | $199.53 | $380.19 |