- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $700.56 / $1,282.02 / $1,730.73
| Facility | | $700.56 | $1,282.02 | $1,730.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.41 / $525.41 / $525.41
| Professional | | $525.41 | $525.41 | $525.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $910.73 / $945.76 / $945.76
| Facility | | $910.73 | $945.76 | $945.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.41 / $1,156.41 / $1,156.41
| Professional | | $1,156.41 | $1,156.41 | $1,156.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $42.50
| Professional | | $17.00 | $20.00 | $42.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.24 / $420.34 / $1,190.95
| Professional | | $294.24 | $420.34 | $1,190.95 |