- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $259.93 / $454.22 / $8,005.65
| Facility | | $259.93 | $454.22 | $8,005.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.37 / $287.48 / $454.22
| Professional | | $214.37 | $287.48 | $454.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.89 / $368.13 / $631.10
| Professional | | $231.89 | $368.13 | $631.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,565.42 / $2,565.42 / $5,130.85
| Facility | | $2,565.42 | $2,565.42 | $5,130.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.25 / $441.19 / $900.72
| Professional | | $328.25 | $441.19 | $900.72 |