- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.94 / $399.53 / $8,882.15
| Facility | | $309.94 | $399.53 | $8,882.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.60 / $137.84 / $169.95
| Professional | | $120.60 | $137.84 | $169.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.11 / $177.89 / $229.31
| Professional | | $131.11 | $177.89 | $229.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,064.61 / $1,553.30 / $6,132.00
| Facility | | $1,064.61 | $1,553.30 | $6,132.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.86 / $189.61 / $372.73
| Professional | | $137.86 | $189.61 | $372.73 |