- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.41 / $582.29 / $3,067.35
| Facility | | $297.41 | $582.29 | $3,067.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.58 / $242.33 / $317.60
| Professional | | $6.58 | $242.33 | $317.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.76 / $116.76 / $116.76
| Professional | | $116.76 | $116.76 | $116.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.47 / $128.47 / $319.02
| Professional | | $128.47 | $128.47 | $319.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.47 / $128.47 / $128.47
| Professional | | $128.47 | $128.47 | $128.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $3,000.00 / $4,410.00
| Professional | | $2,500.00 | $3,000.00 | $4,410.00 |