- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,513.56 / $3,981.07
| Facility | | $588.84 | $1,513.56 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $213.80 / $389.05
| Professional | | $112.20 | $213.80 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $151.36 / $234.42
| Professional | | $100.00 | $151.36 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $190.55 / $288.40
| Professional | | $112.20 | $190.55 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $173.78 / $269.15
| Professional | | $120.23 | $173.78 | $269.15 |