- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.54 / $3,301.73 / $5,295.30
| Facility | | $203.54 | $3,301.73 | $5,295.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.82 / $231.36 / $260.95
| Professional | | $179.82 | $231.36 | $260.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.70 / $293.22 / $385.73
| Professional | | $193.70 | $293.22 | $385.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,038.17 / $4,038.17 / $4,038.17
| Facility | | $4,038.17 | $4,038.17 | $4,038.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.99 / $351.49 / $585.16
| Professional | | $236.99 | $351.49 | $585.16 |