- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $5,128.61 / $7,762.47
| Facility | | $275.42 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $257.04 / $288.40
| Professional | | $162.18 | $257.04 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $323.59 / $588.84
| Professional | | $275.42 | $323.59 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $281.84 / $741.31
| Professional | | $229.09 | $281.84 | $741.31 |