- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.23 / $1,413.55 / $3,706.14
| Facility | | $117.23 | $1,413.55 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.08 / $94.55 / $180.07
| Professional | | $38.08 | $94.55 | $180.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.35 / $141.19 / $241.98
| Professional | | $57.35 | $141.19 | $241.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.27 / $133.15 / $356.26
| Professional | | $76.27 | $133.15 | $356.26 |
- 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
- $167.72 / $222.20 / $372.00
| Professional | | $167.72 | $222.20 | $372.00 |