- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $3,162.28 / $13,489.63
| Facility | | $446.68 | $3,162.28 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $1,949.84
| Professional | | $316.23 | $316.23 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Professional | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |