- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $3,388.44 / $4,466.84
| Facility | | $363.08 | $3,388.44 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $251.19 / $549.54
| Professional | | $100.00 | $251.19 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $181.97 / $309.03
| Facility | | $64.57 | $181.97 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $251.19 / $489.78
| Professional | | $199.53 | $251.19 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,445.44 / $2,344.23
| Facility | | $794.33 | $1,445.44 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,412.54 / $2,187.76
| Facility | | $691.83 | $1,412.54 | $2,187.76 |