- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $2,238.72 / $5,248.07
| Facility | | $338.84 | $2,238.72 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.00 / $1.00 / $229.09
| Professional | | $1.00 | $1.00 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Facility | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $1,513.56 / $2,511.89
| Facility | | $354.81 | $1,513.56 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $47.86 / $60.26
| Professional | | $34.67 | $47.86 | $60.26 |