- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $619.38 / $736.14 / $3,706.14
| Facility | | $619.38 | $736.14 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.61 / $55.12 / $89.70
| Professional | | $38.61 | $55.12 | $89.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.57 / $58.45 / $106.08
| Professional | | $38.57 | $58.45 | $106.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.75 / $82.09 / $114.87
| Professional | | $54.75 | $82.09 | $114.87 |
- 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
- $50.02 / $79.62 / $127.82
| Professional | | $50.02 | $79.62 | $127.82 |