- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $642.52 / $2,162.92 / $3,706.14
| Facility | | $642.52 | $2,162.92 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.20 / $146.80 / $194.75
| Professional | | $119.20 | $146.80 | $194.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.79 / $205.98 / $280.00
| Professional | | $134.79 | $205.98 | $280.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.55 / $218.08 / $402.10
| Professional | | $156.55 | $218.08 | $402.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.04 / $217.57 / $364.14
| Professional | | $151.04 | $217.57 | $364.14 |