- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $3,981.07
| Facility | | $676.08 | $676.08 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $154.88 / $407.38
| Professional | | $100.00 | $154.88 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $144.54 / $223.87
| Professional | | $97.72 | $144.54 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $213.80 / $288.40
| Professional | | $131.83 | $213.80 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,454.71 / $6,025.60
| Facility | | $1,380.38 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $165.96 / $275.42
| Professional | | $104.71 | $165.96 | $275.42 |