- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $529.17 / $998.58 / $1,577.28
| Facility | | $529.17 | $998.58 | $1,577.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $949.73 / $1,512.90 / $2,020.54
| Facility | | $949.73 | $1,512.90 | $2,020.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.55 / $307.55 / $307.55
| Professional | | $307.55 | $307.55 | $307.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.75 / $298.43 / $319.62
| Facility | | $295.75 | $298.43 | $319.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.92 / $47.92 / $47.92
| Professional | | $47.92 | $47.92 | $47.92 |