- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $346.74 / $1,698.24
| Facility | | $177.83 | $346.74 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $56.23 / $141.25
| Professional | | $56.23 | $56.23 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $436.52
| Facility | | $346.74 | $346.74 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $478.63 / $676.08
| Facility | | $302.00 | $478.63 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,884.03 / $7,762.47
| Facility | | $1,318.26 | $2,884.03 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $125.89 / $141.25
| Professional | | $39.81 | $125.89 | $141.25 |