- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $3,630.78 / $14,125.38
| Facility | | $758.58 | $3,630.78 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $218.78 / $407.38
| Professional | | $134.90 | $218.78 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $234.42 / $346.74
| Professional | | $190.55 | $234.42 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $234.42 / $269.15
| Professional | | $234.42 | $234.42 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $1,288.25 / $2,041.74
| Facility | | $199.53 | $1,288.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $331.13 / $616.60
| Professional | | $158.49 | $331.13 | $616.60 |