- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.77 / $1,268.00 / $2,250.00
| Facility | | $562.77 | $1,268.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.76 / $562.77 / $562.77
| Professional | | $316.76 | $562.77 | $562.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.53 / $383.81 / $475.19
| Professional | | $365.53 | $383.81 | $475.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.07 / $357.30 / $576.82
| Professional | | $330.07 | $357.30 | $576.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,754.00 / $5,201.00
| Facility | | $650.00 | $1,754.00 | $5,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.18 / $352.33 / $480.15
| Professional | | $250.18 | $352.33 | $480.15 |