- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $1,819.70 / $2,884.03
| Facility | | $309.03 | $1,819.70 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $316.23 / $478.63
| Professional | | $251.19 | $316.23 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $199.53 / $1,096.48
| Facility | | $190.55 | $199.53 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Professional | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $416.87 / $851.14
| Facility | | $295.12 | $416.87 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $39.81 / $60.26
| Professional | | $34.67 | $39.81 | $60.26 |