- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $313.39 / $357.27 / $1,076.82
| Facility | | $313.39 | $357.27 | $1,076.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.22 / $328.30 / $376.20
| Professional | | $296.22 | $328.30 | $376.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $601.53 / $1,657.66 / $4,341.62
| Facility | | $601.53 | $1,657.66 | $4,341.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.11 / $231.11 / $346.67
| Professional | | $231.11 | $231.11 | $346.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.02 / $358.36 / $644.69
| Professional | | $260.02 | $358.36 | $644.69 |