- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $5,248.07 / $8,709.64
| Facility | | $1,288.25 | $5,248.07 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $371.54 / $2,630.27
| Professional | | $112.20 | $371.54 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $97.72 / $97.72
| Professional | | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $758.58 / $1,949.84
| Facility | | $173.78 | $758.58 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $56.23 / $56.23
| Facility | | $56.23 | $56.23 | $56.23 |