- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $478.63 / $1,122.02
| Facility | | $338.84 | $478.63 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $245.47 / $380.19
| Professional | | $194.98 | $245.47 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $457.09 / $891.25
| Facility | | $363.08 | $457.09 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $190.55 / $302.00
| Professional | | $190.55 | $190.55 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $263.03 / $309.03
| Facility | | $245.47 | $263.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $1,023.29 / $1,023.29
| Professional | | $275.42 | $1,023.29 | $1,023.29 |