- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $886.70 / $1,007.62 / $1,589.53
| Facility | | $886.70 | $1,007.62 | $1,589.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.36 / $1,152.79 / $1,309.99
| Professional | | $514.36 | $1,152.79 | $1,309.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.00 / $1,589.17 / $1,589.17
| Professional | | $558.00 | $1,589.17 | $1,589.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $70.00
| Professional | | $50.00 | $50.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,340.15 / $1,340.15 / $1,340.15
| Facility | | $1,340.15 | $1,340.15 | $1,340.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.05 / $1,589.17 / $1,589.17
| Professional | | $912.05 | $1,589.17 | $1,589.17 |