- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.32 / $116.32 / $3,790.42
| Facility | | $116.32 | $116.32 | $3,790.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.32 / $177.37 / $259.55
| Professional | | $116.32 | $177.37 | $259.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.39 / $389.25 / $392.17
| Professional | | $293.39 | $389.25 | $392.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.57 / $358.00 / $521.10
| Professional | | $237.57 | $358.00 | $521.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.32 / $267.52 / $423.47
| Facility | | $116.32 | $267.52 | $423.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.75 / $242.93 / $1,125.58
| Professional | | $150.75 | $242.93 | $1,125.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.34 / $242.93 / $505.29
| Professional | | $162.34 | $242.93 | $505.29 |