- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.66 / $3,259.25 / $6,446.00
| Facility | | $236.66 | $3,259.25 | $6,446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.25 / $254.62 / $458.37
| Professional | | $61.25 | $254.62 | $458.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.40 / $317.43 / $556.30
| Facility | | $126.40 | $317.43 | $556.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.40 / $313.00 / $479.06
| Facility | | $126.40 | $313.00 | $479.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,026.00 / $1,623.00 / $2,126.00
| Facility | | $1,026.00 | $1,623.00 | $2,126.00 |