- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $946.66 / $1,518.41 / $3,955.04
| Facility | | $946.66 | $1,518.41 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.13 / $206.15 / $277.39
| Professional | | $135.13 | $206.15 | $277.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.94 / $259.83 / $337.31
| Professional | | $164.94 | $259.83 | $337.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $275.52 / $436.50
| Professional | | $150.00 | $275.52 | $436.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.20 / $302.57 / $386.67
| Professional | | $186.20 | $302.57 | $386.67 |