- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $1,621.81 / $5,248.07
| Facility | | $229.09 | $1,621.81 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $316.23 / $630.96
| Professional | | $181.97 | $316.23 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $251.19 / $371.54
| Professional | | $169.82 | $251.19 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $7,244.36 / $27,542.29
| Facility | | $3,388.44 | $7,244.36 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $288.40
| Professional | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $257.04 / $489.78
| Professional | | $194.98 | $257.04 | $489.78 |