- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $730.20 / $1,543.03 / $5,506.50
| Facility | | $730.20 | $1,543.03 | $5,506.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.27 / $157.22 / $191.74
| Professional | | $136.27 | $157.22 | $191.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.14 / $224.15 / $319.18
| Professional | | $164.14 | $224.15 | $319.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.54 / $297.70 / $429.28
| Professional | | $221.54 | $297.70 | $429.28 |
- 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
- $146.77 / $218.07 / $453.05
| Professional | | $146.77 | $218.07 | $453.05 |