- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $635.10 / $1,379.86 / $5,008.18
| Facility | | $635.10 | $1,379.86 | $5,008.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.12 / $115.48 / $142.87
| Professional | | $78.12 | $115.48 | $142.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.66 / $144.19 / $212.44
| Professional | | $94.66 | $144.19 | $212.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.05 / $184.22 / $311.27
| Professional | | $125.05 | $184.22 | $311.27 |
- 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
- $108.40 / $172.50 / $290.76
| Professional | | $108.40 | $172.50 | $290.76 |