- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $854.50 / $1,311.61 / $3,955.04
| Facility | | $854.50 | $1,311.61 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.62 / $186.74 / $259.61
| Professional | | $133.62 | $186.74 | $259.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.52 / $233.44 / $377.70
| Professional | | $152.52 | $233.44 | $377.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.51 / $296.64 / $518.96
| Professional | | $172.51 | $296.64 | $518.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.35 / $297.05 / $455.56
| Professional | | $190.35 | $297.05 | $455.56 |