- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $6,456.54 / $8,709.64
| Facility | | $660.69 | $6,456.54 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $691.83
| Professional | | $660.69 | $660.69 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $1,513.56
| Facility | | $660.69 | $660.69 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,548.13 / $6,606.93
| Facility | | $1,122.02 | $3,548.13 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |