- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $393.47 / $767.27 / $2,581.25
| Facility | | $393.47 | $767.27 | $2,581.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.80 / $487.57 / $635.71
| Professional | | $310.80 | $487.57 | $635.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $612.41 / $985.20 / $1,352.40
| Facility | | $612.41 | $985.20 | $1,352.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.55 / $228.18 / $231.83
| Professional | | $182.55 | $228.18 | $231.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $550.00 / $1,986.06 / $13,785.00
| Facility | | $550.00 | $1,986.06 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.50 / $550.00 / $550.00
| Professional | | $467.50 | $550.00 | $550.00 |