- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,318.26 / $3,890.45
| Facility | | $676.08 | $1,318.26 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $1,174.90 / $3,715.35
| Professional | | $549.54 | $1,174.90 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $416.87 / $2,630.27
| Facility | | $190.55 | $416.87 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $478.63 / $1,202.26
| Facility | | $190.55 | $478.63 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $57.54 / $58.88
| Professional | | $57.54 | $57.54 | $58.88 |