- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.14 / $650.64 / $8,005.65
| Facility | | $376.14 | $650.64 | $8,005.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.35 / $233.18 / $253.17
| Professional | | $141.35 | $233.18 | $253.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.05 / $253.49 / $414.89
| Professional | | $182.05 | $253.49 | $414.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,597.54 / $4,597.54 / $4,597.54
| Facility | | $4,597.54 | $4,597.54 | $4,597.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.66 / $349.76 / $537.27
| Professional | | $235.66 | $349.76 | $537.27 |