- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $661.79 / $2,870.00 / $4,387.00
| Facility | | $661.79 | $2,870.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.55 / $408.51 / $1,152.00
| Professional | | $208.55 | $408.51 | $1,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $432.21 / $561.58 / $818.38
| Facility | | $432.21 | $561.58 | $818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $658.00 / $4,445.00 / $4,912.00
| Facility | | $658.00 | $4,445.00 | $4,912.00 |