- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $7,585.78 / $9,772.37
| Facility | | $4,265.80 | $7,585.78 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $549.54 / $7,585.78
| Professional | | $389.05 | $549.54 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $269.15 / $467.74
| Facility | | $147.91 | $269.15 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $54.95
| Professional | | $30.20 | $30.20 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $1,202.26 / $3,548.13
| Facility | | $380.19 | $1,202.26 | $3,548.13 |