- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.64 / $1,518.41 / $3,955.04
| Facility | | $416.64 | $1,518.41 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.07 / $121.40 / $197.15
| Professional | | $90.07 | $121.40 | $197.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.12 / $140.51 / $239.02
| Professional | | $115.12 | $140.51 | $239.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.03 / $177.89 / $241.32
| Professional | | $158.03 | $177.89 | $241.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.86 / $172.96 / $279.35
| Professional | | $106.86 | $172.96 | $279.35 |