- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,148.15 / $1,905.46
| Facility | | $616.60 | $1,148.15 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,778.28 / $2,041.74
| Facility | | $398.11 | $1,778.28 | $2,041.74 |
- 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
- $380.19 / $1,698.24 / $2,570.40
| Facility | | $380.19 | $1,698.24 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $47.86 / $50.12
| Professional | | $47.86 | $47.86 | $50.12 |