- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.67 / $240.16 / $3,830.87
| Facility | | $97.67 | $240.16 | $3,830.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.87 / $202.77 / $220.11
| Professional | | $84.87 | $202.77 | $220.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.98 / $171.36 / $352.98
| Professional | | $113.98 | $171.36 | $352.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,421.05 / $1,421.05 / $1,889.53
| Facility | | $1,421.05 | $1,421.05 | $1,889.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.38 / $307.33 / $691.58
| Professional | | $240.38 | $307.33 | $691.58 |