- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.61 / $508.19 / $1,955.82
| Facility | | $260.61 | $508.19 | $1,955.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.61 / $336.43 / $499.51
| Professional | | $260.61 | $336.43 | $499.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.77 / $195.69 / $322.95
| Facility | | $193.77 | $195.69 | $322.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.50 / $168.50 / $210.63
| Professional | | $168.50 | $168.50 | $210.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.00 / $473.66 / $13,785.00
| Facility | | $300.00 | $473.66 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.00 / $300.00 / $300.00
| Professional | | $255.00 | $300.00 | $300.00 |