- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,047.13 / $1,995.26
| Facility | | $416.87 | $1,047.13 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $158.49 / $199.53
| Professional | | $100.00 | $158.49 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $223.87 / $223.87
| Professional | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $42.66 / $79.43
| Professional | | $21.38 | $42.66 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $575.44 / $1,659.59
| Facility | | $223.87 | $575.44 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $199.53 / $758.58
| Professional | | $138.04 | $199.53 | $758.58 |