- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $608.16 / $1,106.86 / $1,216.33
| Facility | | $608.16 | $1,106.86 | $1,216.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.45 / $1,106.86 / $1,216.33
| Professional | | $480.45 | $1,106.86 | $1,216.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $790.62 / $821.03 / $821.03
| Facility | | $790.62 | $821.03 | $821.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $25.00 / $50.00
| Professional | | $21.25 | $25.00 | $50.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $547.35 / $547.35 / $608.16
| Facility | | $547.35 | $547.35 | $608.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.43 / $364.90 / $912.26
| Professional | | $255.43 | $364.90 | $912.26 |