- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $1,548.82 / $3,630.78
| Facility | | $380.19 | $1,548.82 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $371.54 / $602.56
| Professional | | $316.23 | $371.54 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $512.86 / $1,148.15
| Professional | | $436.52 | $512.86 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $363.08 / $954.99
| Facility | | $204.17 | $363.08 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Professional | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $831.76
| Professional | | $831.76 | $831.76 | $831.76 |