- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $377.52 / $1,061.67 / $10,708.20
| Facility | | $377.52 | $1,061.67 | $10,708.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.52 / $377.52 / $377.52
| Professional | | $377.52 | $377.52 | $377.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.48 / $577.35 / $976.25
| Professional | | $376.48 | $577.35 | $976.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $356.15 / $356.15 / $377.52
| Facility | | $356.15 | $356.15 | $377.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.89 / $320.89 / $377.52
| Professional | | $320.89 | $320.89 | $377.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.74 / $400.17 / $555.72
| Professional | | $373.74 | $400.17 | $555.72 |