- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $745.94 / $3,908.73 / $5,124.60
| Facility | | $745.94 | $3,908.73 | $5,124.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.14 / $657.14 / $745.94
| Professional | | $657.14 | $657.14 | $745.94 |
- 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
- $416.30 / $416.30 / $520.38
| Professional | | $416.30 | $416.30 | $520.38 |
- 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 |