- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,125.84 / $1,626.60 / $1,626.60
| Facility | | $1,125.84 | $1,626.60 | $1,626.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.37 / $659.93 / $1,125.84
| Professional | | $239.37 | $659.93 | $1,125.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $427.20 / $1,009.26 / $2,495.92
| Facility | | $427.20 | $1,009.26 | $2,495.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.10 / $427.20 / $1,009.26
| Professional | | $347.10 | $427.20 | $1,009.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.34 / $1,125.84 / $2,285.48
| Facility | | $251.34 | $1,125.84 | $2,285.48 |