- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.04 / $267.04 / $267.04
| Facility | | $267.04 | $267.04 | $267.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.00 / $267.04 / $344.41
| Professional | | $261.00 | $267.04 | $344.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.23 / $441.09 / $715.14
| Facility | | $373.23 | $441.09 | $715.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.66 / $910.10 / $2,197.25
| Professional | | $593.66 | $910.10 | $2,197.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $313.89 / $666.92 / $849.25
| Facility | | $313.89 | $666.92 | $849.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.92 / $666.92 / $849.25
| Professional | | $503.92 | $666.92 | $849.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.61 / $910.10 / $1,415.71
| Professional | | $484.61 | $910.10 | $1,415.71 |