- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.09 / $244.86 / $8,912.06
| Facility | | $152.09 | $244.86 | $8,912.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.10 / $79.29 / $99.28
| Professional | | $58.10 | $79.29 | $99.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.71 / $94.46 / $140.54
| Professional | | $62.71 | $94.46 | $140.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,113.20 / $5,113.20 / $5,113.20
| Facility | | $5,113.20 | $5,113.20 | $5,113.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.17 / $110.64 / $218.59
| Professional | | $88.17 | $110.64 | $218.59 |