- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $4,073.80 / $7,762.47
| Facility | | $245.47 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $245.47 / $602.56
| Professional | | $223.87 | $245.47 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Professional | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $15,488.17 / $26,915.35
| Facility | | $3,311.31 | $15,488.17 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $331.13 / $1,380.38
| Professional | | $218.78 | $331.13 | $1,380.38 |