- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.13 / $247.13 / $2,016.60
| Facility | | $247.13 | $247.13 | $2,016.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.13 / $247.13 / $257.02
| Professional | | $247.13 | $247.13 | $257.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.51 / $362.46 / $362.46
| Professional | | $329.51 | $362.46 | $362.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $535.45 / $556.87 / $1,197.50
| Facility | | $535.45 | $556.87 | $1,197.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.39 / $434.53 / $2,567.00
| Professional | | $192.39 | $434.53 | $2,567.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.94 / $669.79 / $669.79
| Professional | | $378.94 | $669.79 | $669.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.38 / $197.71 / $523.91
| Professional | | $138.38 | $197.71 | $523.91 |