- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $803.52 / $2,090.73 / $3,955.04
| Facility | | $803.52 | $2,090.73 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.02 / $167.10 / $239.06
| Professional | | $109.02 | $167.10 | $239.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.72 / $234.67 / $352.23
| Professional | | $142.72 | $234.67 | $352.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.07 / $244.05 / $393.37
| Professional | | $152.07 | $244.05 | $393.37 |
- 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
- $173.78 / $254.39 / $421.96
| Professional | | $173.78 | $254.39 | $421.96 |