- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,235.94 / $4,365.16
| Facility | | $891.25 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $72.44 / $3,715.35
| Professional | | $72.44 | $72.44 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $407.38 / $588.84
| Facility | | $223.87 | $407.38 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $501.19 / $1,202.26
| Facility | | $190.55 | $501.19 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.70 / $53.70 / $54.95
| Professional | | $53.70 | $53.70 | $54.95 |