- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $697.68 / $1,869.59 / $5,681.95
| Facility | | $697.68 | $1,869.59 | $5,681.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.78 / $507.78 / $507.78
| Professional | | $507.78 | $507.78 | $507.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,043.09 / $1,455.56 / $2,275.21
| Facility | | $1,043.09 | $1,455.56 | $2,275.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.34 / $489.34 / $489.34
| Professional | | $489.34 | $489.34 | $489.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.78 / $523.01 / $910.21
| Facility | | $507.78 | $523.01 | $910.21 |