- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $1,513.56 / $3,981.07
| Facility | | $389.05 | $1,513.56 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $109.65 / $380.19
| Professional | | $52.48 | $109.65 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $83.18 / $141.25
| Professional | | $47.86 | $83.18 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $109.65 / $199.53
| Professional | | $44.67 | $109.65 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $100.00 / $181.97
| Professional | | $56.23 | $100.00 | $181.97 |