- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $441.26 / $441.26 / $441.26
| Facility | | $441.26 | $441.26 | $441.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.52 / $378.52 / $441.26
| Professional | | $286.52 | $378.52 | $441.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $534.52 / $939.56 / $5,180.39
| Facility | | $534.52 | $939.56 | $5,180.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.88 / $463.60 / $463.60
| Professional | | $370.88 | $463.60 | $463.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.25 / $208.25 / $208.25
| Professional | | $208.25 | $208.25 | $208.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.76 / $463.60 / $649.04
| Professional | | $311.76 | $463.60 | $649.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.67 / $602.67 / $602.67
| Professional | | $602.67 | $602.67 | $602.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $463.60 / $463.60 / $463.60
| Facility | | $463.60 | $463.60 | $463.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.28 / $356.24 / $649.52
| Professional | | $231.28 | $356.24 | $649.52 |