- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.04 / $528.94 / $10,913.22
| Facility | | $375.04 | $528.94 | $10,913.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.59 / $179.55 / $2,126.41
| Professional | | $44.59 | $179.55 | $2,126.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.21 / $140.77 / $204.01
| Professional | | $112.21 | $140.77 | $204.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.67 / $343.67 / $343.67
| Professional | | $343.67 | $343.67 | $343.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.03 / $2,126.41 / $3,274.67
| Facility | | $78.03 | $2,126.41 | $3,274.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.00 / $329.00 / $329.00
| Professional | | $329.00 | $329.00 | $329.00 |