- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $430.13 / $3,706.14 / $3,955.04
| Facility | | $430.13 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.40 / $297.10 / $408.39
| Professional | | $222.40 | $297.10 | $408.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.97 / $330.79 / $528.74
| Professional | | $257.97 | $330.79 | $528.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.67 / $422.21 / $562.97
| Professional | | $317.67 | $422.21 | $562.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.85 / $402.46 / $609.88
| Professional | | $230.85 | $402.46 | $609.88 |