- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $2,398.83 / $6,606.93
| Facility | | $501.19 | $2,398.83 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $120.23 / $199.53
| Professional | | $95.50 | $120.23 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $151.36 / $190.55
| Professional | | $104.71 | $151.36 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.15 / $177.83 / $1,659.59
| Facility | | $107.15 | $177.83 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $151.36 / $933.25
| Professional | | $109.65 | $151.36 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $616.60 / $1,659.59
| Facility | | $138.04 | $616.60 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $120.23 / $177.83
| Professional | | $89.13 | $120.23 | $177.83 |