- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $2,041.74 / $3,715.35
| Facility | | $660.69 | $2,041.74 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $177.83 / $467.74
| Professional | | $97.72 | $177.83 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $190.55 / $275.42
| Professional | | $154.88 | $190.55 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $263.03 / $323.59
| Professional | | $162.18 | $263.03 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $3,235.94
| Facility | | $794.33 | $794.33 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $288.40 / $588.84
| Professional | | $186.21 | $288.40 | $588.84 |