- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $547.95 / $1,145.06 / $3,300.70
| Facility | | $547.95 | $1,145.06 | $3,300.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.06 / $1,145.06 / $1,145.06
| Professional | | $1,145.06 | $1,145.06 | $1,145.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $433.92 / $809.24 / $1,648.20
| Facility | | $433.92 | $809.24 | $1,648.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.33 / $741.33 / $741.33
| Facility | | $741.33 | $741.33 | $741.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.86 / $520.86 / $520.86
| Professional | | $520.86 | $520.86 | $520.86 |