- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $417.13 / $417.13 / $417.13
| Facility | | $417.13 | $417.13 | $417.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.73 / $407.91 / $417.13
| Professional | | $301.73 | $407.91 | $417.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $583.30 / $689.37 / $1,087.73
| Facility | | $583.30 | $689.37 | $1,087.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.04 / $797.31 / $3,180.32
| Professional | | $530.04 | $797.31 | $3,180.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $490.71 / $641.54 / $742.88
| Facility | | $490.71 | $641.54 | $742.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.38 / $641.54 / $787.50
| Professional | | $583.38 | $641.54 | $787.50 |
- 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
- $515.09 / $797.31 / $1,240.26
| Professional | | $515.09 | $797.31 | $1,240.26 |