- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $3,162.28 / $9,549.93
| Facility | | $239.88 | $3,162.28 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $380.19 / $691.83
| Professional | | $239.88 | $380.19 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $316.23 / $457.09
| Professional | | $245.47 | $316.23 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $6,456.54 / $11,481.54
| Facility | | $1,995.26 | $6,456.54 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $295.12 / $467.74
| Professional | | $218.78 | $295.12 | $467.74 |