- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.17 / $1,543.03 / $3,955.04
| Facility | | $391.17 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.65 / $93.31 / $153.09
| Professional | | $53.65 | $93.31 | $153.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.53 / $102.12 / $151.09
| Professional | | $64.53 | $102.12 | $151.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.53 / $107.52 / $195.38
| Professional | | $70.53 | $107.52 | $195.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.32 / $142.19 / $209.70
| Professional | | $86.32 | $142.19 | $209.70 |