- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Facility | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $234.42 / $371.54
| Professional | | $190.55 | $234.42 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $691.83 / $741.31
| Facility | | $660.69 | $691.83 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $588.84 / $588.84
| Professional | | $588.84 | $588.84 | $588.84 |
- 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
- $234.42 / $234.42 / $512.86
| Professional | | $234.42 | $234.42 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $309.03 / $1,000.00
| Facility | | $128.82 | $309.03 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $223.87 / $2,238.72
| Professional | | $131.83 | $223.87 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $354.81 / $354.81
| Facility | | $263.03 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $223.87 / $309.03
| Professional | | $147.91 | $223.87 | $309.03 |