- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $322.61 / $1,576.00 / $2,657.00
| Facility | | $322.61 | $1,576.00 | $2,657.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.31 / $322.61 / $322.61
| Professional | | $173.31 | $322.61 | $322.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $272.63 / $583.00 / $1,257.58
| Facility | | $272.63 | $583.00 | $1,257.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.22 / $285.45 / $398.45
| Professional | | $78.22 | $285.45 | $398.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.67 / $180.50 / $442.27
| Facility | | $176.67 | $180.50 | $442.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.84 / $307.70 / $638.86
| Professional | | $203.84 | $307.70 | $638.86 |