- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,445.44 / $2,754.23
| Facility | | $316.23 | $1,445.44 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $316.23 / $478.63
| Professional | | $281.84 | $316.23 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Professional | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $537.03 / $794.33
| Facility | | $398.11 | $537.03 | $794.33 |