- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $504.45 / $1,344.79 / $3,955.04
| Facility | | $504.45 | $1,344.79 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.90 / $74.42 / $115.17
| Professional | | $51.90 | $74.42 | $115.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.18 / $84.26 / $145.28
| Professional | | $57.18 | $84.26 | $145.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.56 / $113.97 / $158.26
| Professional | | $77.56 | $113.97 | $158.26 |
- 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
- $56.54 / $111.46 / $172.94
| Professional | | $56.54 | $111.46 | $172.94 |