- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,047.13 / $1,995.26
| Facility | | $416.87 | $1,047.13 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $125.89 / $234.42
| Professional | | $114.82 | $125.89 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $288.40
| Professional | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $208.93 / $302.00
| Professional | | $114.82 | $208.93 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $588.84 / $1,659.59
| Facility | | $338.84 | $588.84 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $147.91 / $295.12
| Professional | | $123.03 | $147.91 | $295.12 |