- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $416.87 / $575.44
| Professional | | $346.74 | $416.87 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Professional | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $316.23
| Facility | | $316.23 | $316.23 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $316.23 / $1,000.00
| Professional | | $52.48 | $316.23 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $446.68 / $3,548.13
| Facility | | $275.42 | $446.68 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $288.40 / $537.03
| Professional | | $177.83 | $288.40 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $218.78 / $407.38
| Facility | | $34.67 | $218.78 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $275.42 / $537.03
| Professional | | $177.83 | $275.42 | $537.03 |