- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $674.02 / $1,059.38 / $2,500.53
| Facility | | $674.02 | $1,059.38 | $2,500.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.18 / $690.18 / $839.19
| Professional | | $690.18 | $690.18 | $839.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.52 / $240.52 / $240.52
| Professional | | $240.52 | $240.52 | $240.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $808.34 / $929.59 / $1,888.53
| Facility | | $808.34 | $929.59 | $1,888.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.37 / $1,384.37 / $1,384.37
| Professional | | $1,384.37 | $1,384.37 | $1,384.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.50 / $525.50 / $525.50
| Professional | | $525.50 | $525.50 | $525.50 |