- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $671.28 / $671.28 / $3,706.14
| Facility | | $671.28 | $671.28 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.01 / $81.81 / $131.18
| Professional | | $46.01 | $81.81 | $131.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.46 / $78.45 / $118.66
| Professional | | $43.46 | $78.45 | $118.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.35 / $109.73 / $158.61
| Professional | | $61.35 | $109.73 | $158.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.31 / $110.80 / $171.36
| Professional | | $68.31 | $110.80 | $171.36 |