- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,659.59 / $3,090.30
| Facility | | $724.44 | $1,659.59 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $501.19
| Professional | | $151.36 | $151.36 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $125.89 / $181.97
| Professional | | $125.89 | $125.89 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,659.59 / $3,090.30
| Facility | | $724.44 | $1,659.59 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $158.49 / $416.87
| Professional | | $151.36 | $158.49 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $151.36 / $331.13
| Professional | | $125.89 | $151.36 | $331.13 |