- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $315.26 / $1,518.41 / $3,955.04
| Facility | | $315.26 | $1,518.41 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.59 / $125.38 / $161.68
| Professional | | $88.59 | $125.38 | $161.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.36 / $153.84 / $197.57
| Professional | | $107.36 | $153.84 | $197.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.31 / $171.54 / $259.11
| Professional | | $103.31 | $171.54 | $259.11 |
- 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
- $124.13 / $179.60 / $274.73
| Professional | | $124.13 | $179.60 | $274.73 |