- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $2,691.53
| Facility | | $812.83 | $1,148.15 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $870.96 / $1,348.96
| Professional | | $537.03 | $870.96 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,096.48 / $2,137.96
| Facility | | $870.96 | $1,096.48 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $758.58 / $1,230.27
| Professional | | $512.86 | $758.58 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $338.84 / $645.65
| Facility | | $309.03 | $338.84 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $1,445.44
| Professional | | $1,202.26 | $1,445.44 | $1,445.44 |