- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.10 / $1,074.18 / $2,180.37
| Facility | | $457.10 | $1,074.18 | $2,180.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.10 / $457.10 / $466.33
| Professional | | $457.10 | $457.10 | $466.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.94 / $51.59 / $77.38
| Professional | | $41.94 | $51.59 | $77.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $577.85 / $6,800.86 / $15,001.88
| Facility | | $577.85 | $6,800.86 | $15,001.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.08 / $7,650.96 / $13,501.70
| Professional | | $600.08 | $7,650.96 | $13,501.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.85 / $525.46 / $900.49
| Professional | | $371.85 | $525.46 | $900.49 |