- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.42 / $1,543.03 / $3,955.04
| Facility | | $562.42 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.72 / $147.44 / $216.44
| Professional | | $107.72 | $147.44 | $216.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.36 / $189.08 / $241.09
| Professional | | $132.36 | $189.08 | $241.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.18 / $205.20 / $318.68
| Professional | | $124.18 | $205.20 | $318.68 |
- 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
- $156.09 / $220.89 / $334.68
| Professional | | $156.09 | $220.89 | $334.68 |