- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $369.56 / $524.36 / $1,261.41
| Facility | | $369.56 | $524.36 | $1,261.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.00 / $251.14 / $604.08
| Professional | | $110.00 | $251.14 | $604.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.14 / $462.31 / $993.24
| Facility | | $291.14 | $462.31 | $993.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.12 / $220.60 / $505.20
| Professional | | $101.12 | $220.60 | $505.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,922.50 / $2,922.50 / $2,922.50
| Facility | | $2,922.50 | $2,922.50 | $2,922.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.09 / $2,380.44 / $2,380.44
| Professional | | $771.09 | $2,380.44 | $2,380.44 |