- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $798.37 / $2,911.82 / $3,565.80
| Facility | | $798.37 | $2,911.82 | $3,565.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.32 / $798.38 / $798.38
| Professional | | $410.32 | $798.38 | $798.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.10 / $487.10 / $487.10
| Professional | | $487.10 | $487.10 | $487.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.54 / $478.54 / $478.54
| Facility | | $478.54 | $478.54 | $478.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.51 / $291.51 / $291.51
| Professional | | $291.51 | $291.51 | $291.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $753.66 / $753.66 / $753.66
| Professional | | $753.66 | $753.66 | $753.66 |