- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $3,162.28 / $7,762.47
| Facility | | $190.55 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $190.55 / $338.84
| Professional | | $44.67 | $190.55 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,698.24 / $4,897.79
| Professional | | $1,230.27 | $1,698.24 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $93.33 / $93.33
| Professional | | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $549.54 / $2,511.89
| Facility | | $213.80 | $549.54 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.11 / $87.10 / $2,290.87
| Professional | | $33.11 | $87.10 | $2,290.87 |