- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $429.66 / $2,778.87 / $3,955.04
| Facility | | $429.66 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.01 / $156.79 / $217.83
| Professional | | $126.01 | $156.79 | $217.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.25 / $286.87 / $384.39
| Professional | | $184.25 | $286.87 | $384.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.08 / $277.89 / $441.05
| Professional | | $172.08 | $277.89 | $441.05 |
- 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
- $173.83 / $305.73 / $475.47
| Professional | | $173.83 | $305.73 | $475.47 |