- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.17 / $298.61 / $6,907.00
| Facility | | $199.17 | $298.61 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.46 / $144.85 / $253.06
| Professional | | $113.46 | $144.85 | $253.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.31 / $204.56 / $332.45
| Professional | | $149.31 | $204.56 | $332.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Facility | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.35 / $193.86 / $472.23
| Professional | | $136.35 | $193.86 | $472.23 |