- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $255.98 / $1,543.03 / $3,955.04
| Facility | | $255.98 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.30 / $115.33 / $169.68
| Professional | | $84.30 | $115.33 | $169.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.77 / $145.61 / $188.27
| Professional | | $101.77 | $145.61 | $188.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.54 / $161.87 / $246.25
| Professional | | $96.54 | $161.87 | $246.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.00 / $1,183.00 / $3,774.00
| Facility | | $437.00 | $1,183.00 | $3,774.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.65 / $171.38 / $244.67
| Professional | | $121.65 | $171.38 | $244.67 |