- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.14 / $1,887.62 / $2,703.62
| Facility | | $320.14 | $1,887.62 | $2,703.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.70 / $164.35 / $250.38
| Professional | | $80.70 | $164.35 | $250.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.00 / $326.00 / $717.00
| Professional | | $169.00 | $326.00 | $717.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.83 / $216.12 / $571.58
| Professional | | $122.83 | $216.12 | $571.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.55 / $515.42 / $814.00
| Professional | | $336.55 | $515.42 | $814.00 |