- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.58 / $1,543.03 / $6,069.84
| Facility | | $660.58 | $1,543.03 | $6,069.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.95 / $157.46 / $241.47
| Professional | | $111.95 | $157.46 | $241.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.48 / $159.26 / $302.43
| Professional | | $127.48 | $159.26 | $302.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.32 / $238.89 / $295.02
| Professional | | $168.32 | $238.89 | $295.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.54 / $214.24 / $331.09
| Professional | | $136.54 | $214.24 | $331.09 |