- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.54 / $348.83 / $3,298.03
| Facility | | $267.54 | $348.83 | $3,298.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.83 / $3,004.83 / $6,220.18
| Professional | | $348.83 | $3,004.83 | $6,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.05 / $949.80 / $5,838.74
| Professional | | $750.05 | $949.80 | $5,838.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.52 / $1,936.10 / $2,231.55
| Professional | | $381.52 | $1,936.10 | $2,231.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.28 / $1,779.10 / $3,340.52
| Professional | | $170.28 | $1,779.10 | $3,340.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.25 / $2,784.95 / $5,436.79
| Professional | | $1,230.25 | $2,784.95 | $5,436.79 |