- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $516.61 / $1,837.40 / $2,861.18
| Facility | | $516.61 | $1,837.40 | $2,861.18 |
- 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
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- 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 / $858.15 / $1,411.89
| Facility | | $507.78 | $858.15 | $1,411.89 |