- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $761.67 / $2,397.12 / $5,215.16
| Facility | | $761.67 | $2,397.12 | $5,215.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.78 / $507.78 / $910.21
| Professional | | $507.78 | $507.78 | $910.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.35 / $1,648.48 / $3,094.62
| Facility | | $1,216.35 | $1,648.48 | $3,094.62 |
- 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 / $964.78 / $2,611.64
| Facility | | $507.78 | $964.78 | $2,611.64 |