- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $920.63 / $1,100.25 / $2,200.50
| Facility | | $920.63 | $1,100.25 | $2,200.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.23 / $836.47 / $1,032.19
| Professional | | $691.23 | $836.47 | $1,032.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.55 / $2,475.73 / $4,125.43
| Facility | | $630.55 | $2,475.73 | $4,125.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.09 / $630.55 / $733.03
| Professional | | $528.09 | $630.55 | $733.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $360.74 / $360.74
| Professional | | $360.74 | $360.74 | $360.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $836.47 / $920.12 / $1,238.63
| Facility | | $836.47 | $920.12 | $1,238.63 |