- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $557.50 / $1,093.45 / $3,955.04
| Facility | | $557.50 | $1,093.45 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.37 / $198.59 / $275.02
| Professional | | $152.37 | $198.59 | $275.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.99 / $250.33 / $404.68
| Professional | | $176.99 | $250.33 | $404.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.58 / $348.08 / $557.85
| Professional | | $202.58 | $348.08 | $557.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.11 / $320.37 / $599.13
| Professional | | $204.11 | $320.37 | $599.13 |