- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $8,511.38 / $8,511.38
| Facility | | $812.83 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $812.83
| Professional | | $616.60 | $616.60 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,238.72 / $3,311.31
| Facility | | $1,348.96 | $2,238.72 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,398.83 / $2,884.03
| Facility | | $1,318.26 | $2,398.83 | $2,884.03 |