- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.78 / $1,584.95 / $2,420.04
| Facility | | $507.78 | $1,584.95 | $2,420.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.78 / $507.78 / $744.10
| Professional | | $507.78 | $507.78 | $744.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $717.31 / $1,388.73 / $2,152.21
| Facility | | $717.31 | $1,388.73 | $2,152.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.34 / $707.34 / $707.34
| Facility | | $707.34 | $707.34 | $707.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.34 / $489.34 / $489.34
| Professional | | $489.34 | $489.34 | $489.34 |