- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,548.13 / $9,772.37
| Facility | | $1,096.48 | $3,548.13 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $1,698.24 / $6,918.31
| Professional | | $467.74 | $1,698.24 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,165.95 / $13,489.63
| Facility | | $3,630.78 | $6,165.95 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $295.12
| Professional | | $0.02 | $0.02 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |