- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $463.62 / $516.61 / $3,140.99
| Facility | | $463.62 | $516.61 | $3,140.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.61 / $516.61 / $529.86
| Professional | | $516.61 | $516.61 | $529.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.32 / $662.32 / $905.72
| Professional | | $662.32 | $662.32 | $905.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,203.71 / $1,631.63 / $3,776.43
| Facility | | $1,203.71 | $1,631.63 | $3,776.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $463.62 / $662.32 / $821.28
| Facility | | $463.62 | $662.32 | $821.28 |
- 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
- $278.17 / $397.39 / $662.32
| Professional | | $278.17 | $397.39 | $662.32 |