- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,445.44 / $2,630.27
| Facility | | $691.83 | $1,445.44 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $1,202.26 / $4,365.16
| Professional | | $131.83 | $1,202.26 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $724.44 / $977.24
| Facility | | $616.60 | $724.44 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $562.34 / $1,548.82
| Facility | | $251.19 | $562.34 | $1,548.82 |