- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,174.90 / $4,897.79
| Facility | | $316.23 | $1,174.90 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $457.09 / $933.25
| Professional | | $371.54 | $457.09 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $489.78 / $575.44
| Professional | | $380.19 | $489.78 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $467.74 / $891.25
| Professional | | $389.05 | $467.74 | $891.25 |