- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $333.22 / $782.36 / $1,343.02
| Facility | | $333.22 | $782.36 | $1,343.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.74 / $317.60 / $317.60
| Professional | | $207.74 | $317.60 | $317.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.00 / $170.00 / $182.00
| Professional | | $170.00 | $170.00 | $182.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.32 / $230.32 / $230.32
| Facility | | $230.32 | $230.32 | $230.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.76 / $116.76 / $116.76
| Professional | | $116.76 | $116.76 | $116.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.53 / $329.53 / $329.53
| Professional | | $329.53 | $329.53 | $329.53 |