- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,513.56 / $5,011.87
| Facility | | $776.25 | $1,513.56 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $158.49 / $416.87
| Professional | | $83.18 | $158.49 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $104.71 / $194.98
| Professional | | $70.79 | $104.71 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $141.25 / $257.04
| Professional | | $95.50 | $141.25 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,454.71 / $6,025.60
| Facility | | $1,380.38 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $128.82 / $208.93
| Professional | | $83.18 | $128.82 | $208.93 |