- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $799.44 / $890.81 / $5,416.12
| Facility | | $799.44 | $890.81 | $5,416.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $890.81 / $890.81 / $913.65
| Professional | | $890.81 | $890.81 | $913.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.06 / $1,142.06 / $1,561.77
| Professional | | $1,142.06 | $1,142.06 | $1,561.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,075.58 / $2,813.47 / $6,511.81
| Facility | | $2,075.58 | $2,813.47 | $6,511.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $799.44 / $1,142.06 / $1,416.16
| Facility | | $799.44 | $1,142.06 | $1,416.16 |
- 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
- $479.67 / $651.41 / $1,039.97
| Professional | | $479.67 | $651.41 | $1,039.97 |