- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.20 / $193.20 / $3,706.14
| Facility | | $193.20 | $193.20 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.57 / $70.58 / $149.03
| Professional | | $48.57 | $70.58 | $149.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.77 / $96.30 / $181.46
| Professional | | $56.77 | $96.30 | $181.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.30 / $105.42 / $191.29
| Professional | | $60.30 | $105.42 | $191.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.37 / $120.55 / $164.75
| Professional | | $83.37 | $120.55 | $164.75 |