- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $803.95 / $1,140.69 / $2,744.07
| Facility | | $803.95 | $1,140.69 | $2,744.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.51 / $615.52 / $1,017.53
| Professional | | $489.51 | $615.52 | $1,017.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $730.86 / $1,042.85 / $2,160.69
| Facility | | $730.86 | $1,042.85 | $2,160.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.66 / $484.66 / $912.03
| Professional | | $484.66 | $484.66 | $912.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.13 / $430.12 / $650.03
| Facility | | $149.13 | $430.12 | $650.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.85 / $1,611.85 / $1,611.85
| Professional | | $1,611.85 | $1,611.85 | $1,611.85 |