- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $371.54 / $3,162.28
| Facility | | $295.12 | $371.54 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $501.19
| Professional | | $295.12 | $295.12 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $371.54 / $758.58
| Professional | | $138.04 | $371.54 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,230.27 / $3,162.28
| Facility | | $371.54 | $1,230.27 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $602.56 / $758.58
| Professional | | $354.81 | $602.56 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $478.63 / $1,047.13
| Facility | | $295.12 | $478.63 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $398.11 / $741.31
| Professional | | $309.03 | $398.11 | $741.31 |