- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $628.98 / $735.01 / $1,127.53
| Facility | | $628.98 | $735.01 | $1,127.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.44 / $300.19 / $762.53
| Professional | | $135.44 | $300.19 | $762.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,322.00 / $1,322.00 / $1,322.00
| Professional | | $1,322.00 | $1,322.00 | $1,322.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $70.00
| Professional | | $50.00 | $58.40 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $802.35 / $802.35 / $802.35
| Facility | | $802.35 | $802.35 | $802.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.21 / $643.29 / $1,322.00
| Professional | | $337.21 | $643.29 | $1,322.00 |