- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.58 / $2,095.00 / $7,838.38
| Facility | | $252.58 | $2,095.00 | $7,838.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.67 / $239.67 / $252.58
| Professional | | $239.67 | $239.67 | $252.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $85.00 / $409.81
| Professional | | $50.00 | $85.00 | $409.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.00 / $5,060.00 / $17,636.00
| Facility | | $582.00 | $5,060.00 | $17,636.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.83 / $390.50 / $538.89
| Professional | | $335.83 | $390.50 | $538.89 |