- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $367.30 / $758.43 / $7,637.29
| Facility | | $367.30 | $758.43 | $7,637.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.91 / $267.63 / $296.86
| Professional | | $142.91 | $267.63 | $296.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.41 / $282.08 / $435.29
| Professional | | $157.41 | $282.08 | $435.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,469.26 / $6,469.26 / $6,469.26
| Facility | | $6,469.26 | $6,469.26 | $6,469.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.97 / $391.79 / $696.53
| Professional | | $275.97 | $391.79 | $696.53 |