- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $870.96 / $1,258.93
| Facility | | $281.84 | $870.96 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $977.24
| Professional | | $660.69 | $660.69 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,071.52 / $1,258.93
| Facility | | $512.86 | $1,071.52 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,071.52 / $1,412.54
| Facility | | $724.44 | $1,071.52 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,000.00 / $1,318.26
| Professional | | $724.44 | $1,000.00 | $1,318.26 |