- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.46 / $215.16 / $1,706.50
| Facility | | $38.46 | $215.16 | $1,706.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.00 / $76.53 / $807.91
| Professional | | $75.00 | $76.53 | $807.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.38 / $263.24 / $380.12
| Facility | | $65.38 | $263.24 | $380.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,200.00 / $3,200.00 / $3,200.00
| Facility | | $3,200.00 | $3,200.00 | $3,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,900.00 / $2,900.00 / $6,237.47
| Professional | | $2,900.00 | $2,900.00 | $6,237.47 |