- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $3,235.94 / $6,760.83
| Facility | | $331.13 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $331.13 / $954.99
| Professional | | $218.78 | $331.13 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $549.54 / $1,949.84
| Facility | | $331.13 | $549.54 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $562.34 / $630.96
| Professional | | $512.86 | $562.34 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $3,548.13
| Facility | | $1,148.15 | $1,621.81 | $3,548.13 |