- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.72 / $3,669.26 / $6,029.22
| Facility | | $137.72 | $3,669.26 | $6,029.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.46 / $132.40 / $306.48
| Professional | | $130.46 | $132.40 | $306.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.87 / $175.85 / $205.14
| Professional | | $125.87 | $175.85 | $205.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,484.24 / $4,484.24 / $4,484.24
| Facility | | $4,484.24 | $4,484.24 | $4,484.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.28 / $147.28 / $226.46
| Professional | | $147.28 | $147.28 | $226.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.83 / $182.31 / $323.82
| Professional | | $139.83 | $182.31 | $323.82 |