- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $640.73 / $1,172.54 / $1,300.68
| Facility | | $640.73 | $1,172.54 | $1,300.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.18 / $506.18 / $506.18
| Professional | | $506.18 | $506.18 | $506.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $961.10 / $961.10 / $961.10
| Facility | | $961.10 | $961.10 | $961.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.63 / $668.63 / $835.78
| Professional | | $668.63 | $668.63 | $835.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.11 / $320.37 / $961.10
| Professional | | $269.11 | $320.37 | $961.10 |