- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,055.70 / $1,771.57 / $2,746.20
| Facility | | $1,055.70 | $1,771.57 | $2,746.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.04 / $585.04 / $1,771.57
| Professional | | $585.04 | $585.04 | $1,771.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $33.60 / $49.59
| Professional | | $30.00 | $33.60 | $49.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $926.83 / $926.83 / $1,132.79
| Facility | | $926.83 | $926.83 | $1,132.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $603.87 / $603.87 / $603.87
| Facility | | $603.87 | $603.87 | $603.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.73 / $1,000.73 / $1,000.73
| Professional | | $1,000.73 | $1,000.73 | $1,000.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $978.95 / $978.95 / $978.95
| Facility | | $978.95 | $978.95 | $978.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.73 / $1,000.73 / $1,000.73
| Professional | | $1,000.73 | $1,000.73 | $1,000.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $100.00
| Professional | | $60.00 | $60.00 | $100.00 |