- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $337.05 / $2,778.87 / $8,447.82
| Facility | | $337.05 | $2,778.87 | $8,447.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.04 / $127.14 / $194.27
| Professional | | $109.04 | $127.14 | $194.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.01 / $181.09 / $216.57
| Professional | | $135.01 | $181.09 | $216.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $189.78 / $266.32
| Professional | | $150.00 | $189.78 | $266.32 |
- 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
- $113.25 / $170.53 / $290.79
| Professional | | $113.25 | $170.53 | $290.79 |