- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.26 / $555.45 / $3,878.29
| Facility | | $140.26 | $555.45 | $3,878.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.26 / $172.66 / $851.88
| Professional | | $140.26 | $172.66 | $851.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.78 / $153.28 / $252.91
| Professional | | $116.78 | $153.28 | $252.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.44 / $436.49 / $2,190.90
| Professional | | $139.44 | $436.49 | $2,190.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.04 / $816.52 / $1,785.46
| Professional | | $694.04 | $816.52 | $1,785.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.07 / $895.85 / $2,090.59
| Professional | | $570.07 | $895.85 | $2,090.59 |