- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.82 / $1,750.44 / $2,441.83
| Facility | | $212.82 | $1,750.44 | $2,441.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.50 / $600.00 / $600.00
| Professional | | $370.50 | $600.00 | $600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $445.07 / $1,345.00 / $1,870.13
| Facility | | $445.07 | $1,345.00 | $1,870.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.13 / $453.51 / $563.07
| Professional | | $340.13 | $453.51 | $563.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.92 / $561.07 / $808.95
| Facility | | $389.92 | $561.07 | $808.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |