- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.62 / $2,145.78 / $7,838.38
| Facility | | $131.62 | $2,145.78 | $7,838.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.56 / $131.62 / $647.29
| Professional | | $103.56 | $131.62 | $647.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.18 / $915.18 / $915.18
| Professional | | $915.18 | $915.18 | $915.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $559.00 / $3,503.00 / $5,060.00
| Facility | | $559.00 | $3,503.00 | $5,060.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.47 / $174.42 / $235.98
| Professional | | $150.47 | $174.42 | $235.98 |