- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $476.76 / $2,521.67 / $5,517.99
| Facility | | $476.76 | $2,521.67 | $5,517.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.96 / $218.00 / $291.51
| Professional | | $176.96 | $218.00 | $291.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.87 / $276.55 / $434.27
| Professional | | $182.87 | $276.55 | $434.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,843.38 / $11,843.38 / $11,843.38
| Facility | | $11,843.38 | $11,843.38 | $11,843.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.42 / $306.10 / $650.02
| Professional | | $240.42 | $306.10 | $650.02 |