- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,348.96 / $3,981.07
| Facility | | $912.01 | $1,348.96 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $389.05 / $812.83
| Professional | | $190.55 | $389.05 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $295.12 / $467.74
| Professional | | $141.25 | $295.12 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $323.59 / $660.69
| Professional | | $154.88 | $323.59 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $275.42 / $602.56
| Professional | | $173.78 | $275.42 | $602.56 |