- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $1,445.44 / $3,162.28
| Facility | | $354.81 | $1,445.44 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $194.98 / $467.74
| Professional | | $109.65 | $194.98 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $1,202.26 / $2,454.71
| Professional | | $131.83 | $1,202.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $194.98 / $389.05
| Professional | | $144.54 | $194.98 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $346.74 / $467.74
| Professional | | $213.80 | $346.74 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,737.80 / $5,128.61
| Facility | | $741.31 | $1,737.80 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $186.21 / $398.11
| Professional | | $120.23 | $186.21 | $398.11 |