- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $2,754.23
| Facility | | $812.83 | $1,148.15 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $588.84 / $977.24
| Professional | | $467.74 | $588.84 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,096.48 / $2,187.76
| Facility | | $891.25 | $1,096.48 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $467.74 / $724.44
| Professional | | $467.74 | $467.74 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $524.81 / $812.83
| Facility | | $263.03 | $524.81 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Professional | | $1,621.81 | $1,621.81 | $1,621.81 |