- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.64 / $575.64 / $575.64
| Facility | | $575.64 | $575.64 | $575.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.17 / $214.00 / $448.75
| Professional | | $87.17 | $214.00 | $448.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.00 / $346.00 / $1,199.00
| Professional | | $224.00 | $346.00 | $1,199.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.76 / $281.82 / $703.13
| Professional | | $127.76 | $281.82 | $703.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.63 / $560.91 / $1,133.58
| Professional | | $325.63 | $560.91 | $1,133.58 |