- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $410.30 / $1,694.00 / $2,441.83
| Facility | | $410.30 | $1,694.00 | $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
- $448.13 / $597.51 / $741.86
| Professional | | $448.13 | $597.51 | $741.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $578.04 / $803.90 / $1,156.77
| Facility | | $578.04 | $803.90 | $1,156.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |