- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $728.92 / $1,025.91 / $3,549.08
| Facility | | $728.92 | $1,025.91 | $3,549.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.78 / $507.78 / $1,067.16
| Professional | | $507.78 | $507.78 | $1,067.16 |
- 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
- $30.00 / $45.00 / $45.00
| Professional | | $30.00 | $45.00 | $45.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,183.54 / $1,518.13 / $2,212.35
| Facility | | $1,183.54 | $1,518.13 | $2,212.35 |