- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $689.67 / $1,026.40 / $2,152.82
| Facility | | $689.67 | $1,026.40 | $2,152.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.91 / $507.78 / $507.78
| Professional | | $468.91 | $507.78 | $507.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,102.24 / $1,995.60 / $3,620.66
| Facility | | $1,102.24 | $1,995.60 | $3,620.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.34 / $489.34 / $489.34
| Professional | | $489.34 | $489.34 | $489.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.78 / $558.55 / $1,052.93
| Facility | | $507.78 | $558.55 | $1,052.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |