- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,445.44 / $2,238.72
| Facility | | $616.60 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $1,862.09 / $2,630.27
| Professional | | $263.03 | $1,862.09 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $724.44 / $977.24
| Facility | | $616.60 | $724.44 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Professional | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $562.34 / $1,548.82
| Facility | | $251.19 | $562.34 | $1,548.82 |