- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,479.11 / $2,754.23
| Facility | | $676.08 | $1,479.11 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $524.81 / $1,122.02
| Facility | | $109.65 | $524.81 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $489.78 / $645.65
| Facility | | $426.58 | $489.78 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $47.86 / $50.12
| Professional | | $47.86 | $47.86 | $50.12 |