- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.56 / $891.56 / $3,706.14
| Facility | | $196.56 | $891.56 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.62 / $100.65 / $132.58
| Professional | | $79.62 | $100.65 | $132.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.50 / $132.09 / $182.55
| Professional | | $86.50 | $132.09 | $182.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.55 / $162.32 / $267.45
| Professional | | $114.55 | $162.32 | $267.45 |
- 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
- $97.88 / $150.74 / $245.63
| Professional | | $97.88 | $150.74 | $245.63 |