- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $421.77 / $421.77 / $3,706.14
| Facility | | $421.77 | $421.77 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.01 / $128.68 / $181.24
| Professional | | $93.01 | $128.68 | $181.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.81 / $182.16 / $229.66
| Professional | | $136.81 | $182.16 | $229.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.40 / $212.81 / $336.96
| Professional | | $130.40 | $212.81 | $336.96 |
- 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
- $137.53 / $200.87 / $369.12
| Professional | | $137.53 | $200.87 | $369.12 |