- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $1,288.25 / $2,344.23
| Facility | | $549.54 | $1,288.25 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $120.23 / $123.03
| Professional | | $114.82 | $120.23 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.89 / $208.93 / $512.86
| Facility | | $125.89 | $208.93 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,479.11 / $2,344.23
| Professional | | $1,023.29 | $1,479.11 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.49 / $125.89 / $208.93
| Facility | | $117.49 | $125.89 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $316.23 / $316.23
| Professional | | $120.23 | $316.23 | $316.23 |