- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.48 / $1,543.03 / $3,955.04
| Facility | | $977.48 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $153.58 / $376.69
| Professional | | $47.86 | $153.58 | $376.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.48 / $154.79 / $227.29
| Professional | | $77.48 | $154.79 | $227.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.41 / $160.60 / $388.14
| Professional | | $84.41 | $160.60 | $388.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.00 / $1,183.00 / $4,915.00
| Facility | | $158.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.30 / $269.05 / $396.72
| Professional | | $188.30 | $269.05 | $396.72 |