- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $543.04 / $1,580.78 / $1,580.78
| Facility | | $543.04 | $1,580.78 | $1,580.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.16 / $527.54 / $615.09
| Professional | | $197.16 | $527.54 | $615.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.83 / $376.04 / $794.82
| Professional | | $187.83 | $376.04 | $794.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,320.00 / $1,320.00 / $1,320.00
| Facility | | $1,320.00 | $1,320.00 | $1,320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.77 / $424.72 / $1,089.05
| Professional | | $312.77 | $424.72 | $1,089.05 |