- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,288.25 / $3,890.45
| Facility | | $501.19 | $1,288.25 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $134.90 / $169.82
| Professional | | $100.00 | $134.90 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,288.25 / $2,630.27
| Facility | | $676.08 | $1,288.25 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $1,047.13 / $2,187.76
| Facility | | $338.84 | $1,047.13 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $181.97 / $309.03
| Professional | | $131.83 | $181.97 | $309.03 |