- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.02 / $1,974.50 / $14,719.50
| Facility | | $582.02 | $1,974.50 | $14,719.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.47 / $339.52 / $350.93
| Professional | | $226.47 | $339.52 | $350.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.06 / $366.85 / $530.01
| Professional | | $258.06 | $366.85 | $530.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,280.31 / $1,280.31 / $1,280.31
| Facility | | $1,280.31 | $1,280.31 | $1,280.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.01 / $406.57 / $922.02
| Professional | | $289.01 | $406.57 | $922.02 |