- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $2,454.71
| Facility | | $794.33 | $1,071.52 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,862.09 / $2,041.74
| Professional | | $977.24 | $1,862.09 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $213.80 / $288.40
| Facility | | $213.80 | $213.80 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.49 / $117.49 / $117.49
| Facility | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $346.74 / $776.25
| Facility | | $128.82 | $346.74 | $776.25 |