- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,096.48 / $1,778.28
| Facility | | $416.87 | $1,096.48 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $436.52
| Professional | | $316.23 | $316.23 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $1,258.93 / $2,630.27
| Facility | | $562.34 | $1,258.93 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $52.48 / $52.48
| Professional | | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $724.44 / $1,000.00
| Facility | | $316.23 | $724.44 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $1,230.27
| Facility | | $891.25 | $891.25 | $1,230.27 |