- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $1,230.27
| Facility | | $446.68 | $446.68 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $128.82 / $151.36
| Professional | | $95.50 | $128.82 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $338.84 / $1,000.00
| Facility | | $302.00 | $338.84 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $114.82 / $114.82
| Professional | | $69.18 | $114.82 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $549.54 / $758.58
| Facility | | $281.84 | $549.54 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $331.13
| Professional | | $173.78 | $173.78 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $186.21
| Professional | | $104.71 | $104.71 | $186.21 |