- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $897.55 / $930.57 / $1,878.56
| Facility | | $897.55 | $930.57 | $1,878.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.65 / $78.65 / $78.65
| Professional | | $78.65 | $78.65 | $78.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.02 / $293.02 / $1,990.36
| Professional | | $293.02 | $293.02 | $1,990.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $516.17 / $907.01 / $4,804.00
| Facility | | $516.17 | $907.01 | $4,804.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.04 / $210.20 / $210.20
| Professional | | $97.04 | $210.20 | $210.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.67 / $203.06 / $302.94
| Professional | | $123.67 | $203.06 | $302.94 |