- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.98 / $3,162.28 / $7,762.47
| Facility | | $194.98 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.70 / $173.78 / $194.98
| Professional | | $53.70 | $173.78 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $1,071.52 / $2,454.71
| Professional | | $91.20 | $1,071.52 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $213.80 / $426.58
| Professional | | $199.53 | $213.80 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,737.80 / $5,128.61
| Facility | | $741.31 | $1,737.80 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $218.78 / $467.74
| Professional | | $144.54 | $218.78 | $467.74 |