- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $836.47 / $996.96 / $1,321.63
| Facility | | $836.47 | $996.96 | $1,321.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $1,032.19
| Professional | | $836.47 | $836.47 | $1,032.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.54 / $343.54 / $343.54
| Professional | | $343.54 | $343.54 | $343.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.28 / $1,096.28 / $1,534.79
| Facility | | $1,096.28 | $1,096.28 | $1,534.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.88 / $1,260.72 / $1,688.27
| Professional | | $1,136.88 | $1,260.72 | $1,688.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $360.74 / $360.74
| Professional | | $360.74 | $360.74 | $360.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $3,000.00
| Professional | | $45.00 | $45.00 | $3,000.00 |