- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $562.34 / $2,089.30
| Facility | | $186.21 | $562.34 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.74 / $117.49 / $263.03
| Professional | | $40.74 | $117.49 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.18 / $53.70 / $109.65
| Professional | | $28.18 | $53.70 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $87.10 / $181.97
| Professional | | $41.69 | $87.10 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,412.54 / $6,456.54
| Facility | | $416.87 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $69.18 / $144.54
| Professional | | $33.88 | $69.18 | $144.54 |