- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $867.30 / $1,316.65 / $2,216.50
| Facility | | $867.30 | $1,316.65 | $2,216.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.18 / $314.18 / $450.36
| Professional | | $314.18 | $314.18 | $450.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $965.57 / $1,988.21 / $3,620.66
| Facility | | $965.57 | $1,988.21 | $3,620.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.02 / $52.02 / $52.02
| Professional | | $52.02 | $52.02 | $52.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $314.18 / $345.60 / $534.11
| Facility | | $314.18 | $345.60 | $534.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |