- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.83 / $327.83 / $2,221.02
| Facility | | $327.83 | $327.83 | $2,221.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.83 / $327.83 / $327.83
| Professional | | $327.83 | $327.83 | $327.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.33 / $491.75 / $646.29
| Professional | | $468.33 | $491.75 | $646.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.13 / $1,153.71 / $2,670.28
| Facility | | $851.13 | $1,153.71 | $2,670.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $365.30 / $468.33 / $562.00
| Facility | | $365.30 | $468.33 | $562.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.70 / $234.17 / $426.47
| Professional | | $196.70 | $234.17 | $426.47 |