- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $2,041.74 / $2,187.76
| Facility | | $316.23 | $2,041.74 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $316.23 / $478.63
| Professional | | $263.03 | $316.23 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,318.26 / $2,187.76
| Facility | | $707.95 | $1,318.26 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $1,122.02 / $1,230.27
| Facility | | $239.88 | $1,122.02 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $398.11 / $676.08
| Facility | | $316.23 | $398.11 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $1,000.00 / $1,513.56
| Facility | | $229.09 | $1,000.00 | $1,513.56 |