- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.82 / $1,355.53 / $3,955.04
| Facility | | $347.82 | $1,355.53 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.28 / $189.94 / $270.25
| Professional | | $136.28 | $189.94 | $270.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.08 / $208.68 / $272.08
| Professional | | $146.08 | $208.68 | $272.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $243.49 / $337.51
| Professional | | $150.00 | $243.49 | $337.51 |
- 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
- $163.81 / $211.03 / $349.83
| Professional | | $163.81 | $211.03 | $349.83 |