- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $1,737.80 / $5,888.44
| Facility | | $288.40 | $1,737.80 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $691.83 / $2,884.03
| Facility | | $575.44 | $691.83 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $1,288.25
| Facility | | $398.11 | $398.11 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $426.58 / $851.14
| Professional | | $199.53 | $426.58 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.96 / $741.31 / $2,187.76
| Facility | | $165.96 | $741.31 | $2,187.76 |