- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $361.61 / $535.16 / $1,157.14
| Facility | | $361.61 | $535.16 | $1,157.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.61 / $361.61 / $361.61
| Professional | | $361.61 | $361.61 | $361.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $313.39 / $313.39 / $1,288.03
| Facility | | $313.39 | $313.39 | $1,288.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.50 / $587.50 / $703.89
| Professional | | $587.50 | $587.50 | $703.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $356.78 / $470.09 / $810.00
| Facility | | $356.78 | $470.09 | $810.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.07 / $87.07 / $723.21
| Professional | | $87.07 | $87.07 | $723.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.07 / $87.07 / $207.31
| Professional | | $87.07 | $87.07 | $207.31 |