- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,122.02 / $1,122.02
| Facility | | $758.58 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $478.63
| Professional | | $478.63 | $478.63 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $2,187.76
| Facility | | $549.54 | $549.54 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $575.44 / $575.44
| Facility | | $389.05 | $575.44 | $575.44 |