- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $662.48 / $3,795.64 / $8,881.37
| Facility | | $662.48 | $3,795.64 | $8,881.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.45 / $170.85 / $170.85
| Professional | | $43.45 | $170.85 | $170.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $336.48 / $1,151.00 / $3,185.00
| Facility | | $336.48 | $1,151.00 | $3,185.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,026.00 / $1,607.00 / $1,966.00
| Facility | | $1,026.00 | $1,607.00 | $1,966.00 |