- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $523.87 / $523.87 / $3,549.14
| Facility | | $523.87 | $523.87 | $3,549.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.87 / $523.87 / $523.87
| Professional | | $523.87 | $523.87 | $523.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.39 / $785.81 / $1,032.78
| Professional | | $748.39 | $785.81 | $1,032.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,360.11 / $1,843.65 / $4,267.14
| Facility | | $1,360.11 | $1,843.65 | $4,267.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $583.74 / $748.39 / $898.07
| Facility | | $583.74 | $748.39 | $898.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.32 / $374.20 / $681.49
| Professional | | $314.32 | $374.20 | $681.49 |