- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $653.11 / $919.46 / $9,405.36
| Facility | | $653.11 | $919.46 | $9,405.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.77 / $314.06 / $380.07
| Professional | | $248.77 | $314.06 | $380.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.72 / $409.58 / $587.48
| Professional | | $279.72 | $409.58 | $587.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,473.18 / $5,473.18 / $5,473.18
| Facility | | $5,473.18 | $5,473.18 | $5,473.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.83 / $283.83 / $799.17
| Professional | | $283.83 | $283.83 | $799.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.00 / $464.14 / $862.78
| Professional | | $342.00 | $464.14 | $862.78 |