- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.50 / $4,803.39 / $8,975.98
| Facility | | $212.50 | $4,803.39 | $8,975.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.30 / $212.51 / $215.09
| Professional | | $208.30 | $212.51 | $215.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.00 / $261.57 / $368.06
| Professional | | $190.00 | $261.57 | $368.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,113.20 / $5,113.20 / $7,304.05
| Facility | | $5,113.20 | $5,113.20 | $7,304.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.53 / $255.63 / $480.08
| Professional | | $197.53 | $255.63 | $480.08 |