- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $623.13 / $1,518.41 / $3,955.04
| Facility | | $623.13 | $1,518.41 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.89 / $126.78 / $212.05
| Professional | | $95.89 | $126.78 | $212.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.78 / $145.49 / $218.26
| Professional | | $114.78 | $145.49 | $218.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.53 / $203.93 / $259.52
| Professional | | $152.53 | $203.93 | $259.52 |
- 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
- $112.91 / $187.45 / $293.36
| Professional | | $112.91 | $187.45 | $293.36 |