- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $6,456.54 / $8,912.51
| Facility | | $3,019.95 | $6,456.54 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $3,019.95 / $8,317.64
| Professional | | $331.13 | $3,019.95 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $354.81 / $426.58
| Professional | | $338.84 | $354.81 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $630.96
| Facility | | $575.44 | $602.56 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.86 / $107.15 / $602.56
| Facility | | $75.86 | $107.15 | $602.56 |