- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $1,288.25 / $1,995.26
| Facility | | $549.54 | $1,288.25 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $114.82 / $275.42
| Professional | | $102.33 | $114.82 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $239.88 / $239.88
| Professional | | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $177.83 / $234.42
| Professional | | $134.90 | $177.83 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $562.34 / $1,479.11
| Facility | | $223.87 | $562.34 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $138.04 / $275.42
| Professional | | $102.33 | $138.04 | $275.42 |