- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $642.52 / $2,362.19 / $3,955.04
| Facility | | $642.52 | $2,362.19 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.67 / $188.03 / $258.42
| Professional | | $75.67 | $188.03 | $258.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.61 / $204.80 / $370.18
| Professional | | $114.61 | $204.80 | $370.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.72 / $209.75 / $503.56
| Professional | | $115.72 | $209.75 | $503.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.65 / $301.85 / $492.41
| Professional | | $235.65 | $301.85 | $492.41 |