- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.33 / $881.20 / $9,721.64
| Facility | | $153.33 | $881.20 | $9,721.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.60 / $245.19 / $342.88
| Professional | | $135.60 | $245.19 | $342.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.93 / $263.25 / $474.33
| Professional | | $182.93 | $263.25 | $474.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,716.74 / $5,716.74 / $5,792.39
| Facility | | $5,716.74 | $5,716.74 | $5,792.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.74 / $455.33 / $734.99
| Professional | | $217.74 | $455.33 | $734.99 |