- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $5,888.44 / $7,943.28
| Facility | | $602.56 | $5,888.44 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $239.88 / $239.88
| Professional | | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $630.96 / $1,949.84
| Facility | | $338.84 | $630.96 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,202.26 / $2,344.23
| Facility | | $436.52 | $1,202.26 | $2,344.23 |