- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.39 / $1,469.36 / $3,447.22
| Facility | | $724.39 | $1,469.36 | $3,447.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.78 / $507.78 / $951.82
| Professional | | $507.78 | $507.78 | $951.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $963.57 / $1,152.99 / $1,457.71
| Facility | | $963.57 | $1,152.99 | $1,457.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.34 / $489.34 / $489.34
| Professional | | $489.34 | $489.34 | $489.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $345.40
| Professional | | $100.00 | $200.00 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |