- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.06 / $8,110.73 / $9,652.53
| Facility | | $317.06 | $8,110.73 | $9,652.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.25 / $219.34 / $317.06
| Professional | | $183.25 | $219.34 | $317.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.44 / $361.95 / $425.33
| Professional | | $254.44 | $361.95 | $425.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.27 / $349.74 / $536.52
| Professional | | $302.27 | $349.74 | $536.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,110.73 / $8,110.73 / $9,652.53
| Facility | | $8,110.73 | $8,110.73 | $9,652.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.25 / $264.75 / $317.06
| Professional | | $183.25 | $264.75 | $317.06 |