- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.50 / $37.43 / $37.43
| Professional | | $29.50 | $37.43 | $37.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $765.99 / $1,102.59 / $1,364.81
| Facility | | $765.99 | $1,102.59 | $1,364.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.20 / $13.20 / $13.20
| Professional | | $13.20 | $13.20 | $13.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |