- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $9,120.11 / $16,595.87
| Facility | | $263.03 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $251.19 / $323.59
| Professional | | $213.80 | $251.19 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,905.46 / $3,890.45
| Facility | | $891.25 | $1,905.46 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $234.42 / $457.09
| Professional | | $213.80 | $234.42 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $302.00 / $562.34
| Facility | | $234.42 | $302.00 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $54.95
| Professional | | $30.20 | $30.20 | $54.95 |