- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $752.91 / $1,105.90 / $2,934.93
| Facility | | $752.91 | $1,105.90 | $2,934.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.49 / $306.14 / $317.60
| Professional | | $203.49 | $306.14 | $317.60 |
- 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
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.93 / $365.26 / $524.38
| Facility | | $292.93 | $365.26 | $524.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.93 / $194.93 / $194.93
| Professional | | $194.93 | $194.93 | $194.93 |