- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $410.30 / $2,149.96 / $2,818.76
| Facility | | $410.30 | $2,149.96 | $2,818.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.30 / $487.58 / $524.72
| Professional | | $410.30 | $487.58 | $524.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $720.25 / $720.25 / $720.25
| Facility | | $720.25 | $720.25 | $720.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.55 / $182.55 / $228.18
| Professional | | $182.55 | $182.55 | $228.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,196.16 / $1,630.39 / $2,375.94
| Facility | | $1,196.16 | $1,630.39 | $2,375.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.88 / $822.20 / $877.43
| Professional | | $742.88 | $822.20 | $877.43 |