- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,513.56 / $3,981.07
| Facility | | $676.08 | $1,513.56 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $363.08 / $954.99
| Professional | | $275.42 | $363.08 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $346.74 / $602.56
| Professional | | $309.03 | $346.74 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $501.19 / $676.08
| Professional | | $363.08 | $501.19 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $7,585.78
| Facility | | $2,570.40 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $416.87 / $741.31
| Professional | | $288.40 | $416.87 | $741.31 |