- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.32 / $363.61 / $2,210.75
| Facility | | $326.32 | $363.61 | $2,210.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.61 / $363.61 / $405.57
| Professional | | $363.61 | $363.61 | $405.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.17 / $489.48 / $643.30
| Professional | | $466.17 | $489.48 | $643.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $847.22 / $1,148.41 / $2,658.00
| Facility | | $847.22 | $1,148.41 | $2,658.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.61 / $466.17 / $559.40
| Facility | | $363.61 | $466.17 | $559.40 |
- 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
- $195.79 / $233.09 / $466.17
| Professional | | $195.79 | $233.09 | $466.17 |