- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.66 / $364.15 / $1,572.03
| Facility | | $145.66 | $364.15 | $1,572.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.66 / $214.37 / $233.61
| Professional | | $145.66 | $214.37 | $233.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $268.64 / $405.84 / $865.38
| Facility | | $268.64 | $405.84 | $865.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.38 / $360.03 / $500.74
| Professional | | $192.38 | $360.03 | $500.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.83 / $8,702.00 / $12,381.00
| Facility | | $274.83 | $8,702.00 | $12,381.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.41 / $164.90 / $280.33
| Professional | | $106.41 | $164.90 | $280.33 |