- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $249.71 / $8,402.91 / $20,122.37
| Facility | | $249.71 | $8,402.91 | $20,122.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.22 / $318.22 / $1,270.80
| Professional | | $318.22 | $318.22 | $1,270.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $814.58 / $814.58 / $814.58
| Facility | | $814.58 | $814.58 | $814.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.45 / $51.54 / $60.64
| Professional | | $42.45 | $51.54 | $60.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.84 / $673.84 / $673.84
| Professional | | $673.84 | $673.84 | $673.84 |