- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.04 / $1,543.03 / $3,955.04
| Facility | | $247.04 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.47 / $270.27 / $392.09
| Professional | | $215.47 | $270.27 | $392.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.46 / $312.60 / $500.90
| Professional | | $242.46 | $312.60 | $500.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.04 / $411.05 / $537.67
| Professional | | $296.04 | $411.05 | $537.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.24 / $1,401.00 / $4,915.00
| Facility | | $503.24 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.19 / $375.14 / $580.53
| Professional | | $215.19 | $375.14 | $580.53 |