- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $897.20 / $4,701.33 / $6,163.76
| Facility | | $897.20 | $4,701.33 | $6,163.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.96 / $780.96 / $955.07
| Professional | | $780.96 | $780.96 | $955.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.07 / $143.07 / $143.07
| Facility | | $143.07 | $143.07 | $143.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.54 / $519.54 / $649.44
| Professional | | $519.54 | $519.54 | $649.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.73 / $323.85 / $471.95
| Facility | | $246.73 | $323.85 | $471.95 |