- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $88.90 / $1,106.91 / $4,089.40
| Facility | | $88.90 | $1,106.91 | $4,089.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.94 / $199.07 / $748.79
| Professional | | $76.94 | $199.07 | $748.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.18 / $169.31 / $1,116.92
| Professional | | $100.18 | $169.31 | $1,116.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,190.29 / $1,190.29 / $1,190.29
| Facility | | $1,190.29 | $1,190.29 | $1,190.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.96 / $1,026.20 / $2,070.78
| Professional | | $707.96 | $1,026.20 | $2,070.78 |