- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.39 / $176.39 / $422.06
| Facility | | $176.39 | $176.39 | $422.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.84 / $176.39 / $387.00
| Professional | | $155.84 | $176.39 | $387.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,144.28 / $3,057.88 / $13,213.43
| Facility | | $1,144.28 | $3,057.88 | $13,213.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.52 / $671.90 / $671.90
| Professional | | $537.52 | $671.90 | $671.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $220.23 / $298.10 / $361.35
| Facility | | $220.23 | $298.10 | $361.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.36 / $1,116.36 / $1,116.36
| Professional | | $1,116.36 | $1,116.36 | $1,116.36 |