- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.98 / $2,398.83 / $6,025.60
| Facility | | $0.98 | $2,398.83 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $1,995.26 / $8,317.64
| Professional | | $245.47 | $1,995.26 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Professional | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $630.96
| Facility | | $575.44 | $602.56 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,862.09 / $3,630.78
| Facility | | $1,230.27 | $1,862.09 | $3,630.78 |