- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,504.00 / $1,504.00 / $1,504.00
| Facility | | $1,504.00 | $1,504.00 | $1,504.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $900.00 / $988.26
| Professional | | $500.00 | $900.00 | $988.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.82 / $196.11 / $244.64
| Facility | | $122.82 | $196.11 | $244.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.58 / $278.08 / $488.86
| Facility | | $247.58 | $278.08 | $488.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.38 / $736.38 / $920.47
| Professional | | $736.38 | $736.38 | $920.47 |