- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,288.25 / $2,454.71
| Facility | | $630.96 | $1,288.25 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $512.86 / $707.95
| Professional | | $457.09 | $512.86 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $812.83 / $977.24
| Professional | | $575.44 | $812.83 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $616.60 / $954.99
| Professional | | $426.58 | $616.60 | $954.99 |