- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $713.50 / $1,944.07 / $2,860.56
| Facility | | $713.50 | $1,944.07 | $2,860.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.18 / $713.50 / $1,391.32
| Professional | | $690.18 | $713.50 | $1,391.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $734.67 / $734.67 / $734.67
| Facility | | $734.67 | $734.67 | $734.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.52 / $240.52 / $240.52
| Professional | | $240.52 | $240.52 | $240.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.68 / $437.68 / $437.68
| Professional | | $437.68 | $437.68 | $437.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,508.50 / $2,331.19 / $2,860.56
| Facility | | $1,508.50 | $2,331.19 | $2,860.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.18 / $839.19 / $1,391.32
| Professional | | $690.18 | $839.19 | $1,391.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.68 / $437.68 / $437.68
| Professional | | $437.68 | $437.68 | $437.68 |