- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $2,089.30 / $3,981.07
| Facility | | $407.38 | $2,089.30 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $346.74 / $870.96
| Professional | | $275.42 | $346.74 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $354.81 / $575.44
| Professional | | $281.84 | $354.81 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $489.78 / $660.69
| Professional | | $323.59 | $489.78 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $380.19 / $691.83
| Professional | | $263.03 | $380.19 | $691.83 |