- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Facility | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $338.84 / $831.76
| Professional | | $263.03 | $338.84 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $467.74
| Professional | | $363.08 | $363.08 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $457.09
| Facility | | $457.09 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $338.84 / $489.78
| Professional | | $338.84 | $338.84 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $954.99 / $1,318.26
| Professional | | $446.68 | $954.99 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $331.13 / $512.86
| Professional | | $223.87 | $331.13 | $512.86 |