- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,754.23 / $6,606.93
| Facility | | $933.25 | $2,754.23 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $467.74 / $4,365.16
| Professional | | $467.74 | $467.74 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $407.38 / $602.56
| Facility | | $223.87 | $407.38 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $501.19 / $1,202.26
| Facility | | $190.55 | $501.19 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.07 / $4.07 / $4.17
| Professional | | $4.07 | $4.07 | $4.17 |