- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $591.66 / $3,530.58 / $5,295.30
| Facility | | $591.66 | $3,530.58 | $5,295.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.17 / $157.33 / $204.28
| Professional | | $100.17 | $157.33 | $204.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.46 / $169.86 / $283.83
| Professional | | $108.46 | $169.86 | $283.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.94 / $241.53 / $2,821.97
| Facility | | $228.94 | $241.53 | $2,821.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.13 / $218.57 / $423.88
| Professional | | $158.13 | $218.57 | $423.88 |