- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.43 / $2,511.89 / $6,760.83
| Facility | | $79.43 | $2,511.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $331.13 / $1,513.56
| Professional | | $125.89 | $331.13 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $724.44 / $2,137.96
| Facility | | $371.54 | $724.44 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $1,202.26 / $2,344.23
| Facility | | $537.03 | $1,202.26 | $2,344.23 |