- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $738.85 / $1,477.70 / $6,274.50
| Facility | | $738.85 | $1,477.70 | $6,274.50 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $445.77 / $948.12 / $1,606.76
| Facility | | $445.77 | $948.12 | $1,606.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $360.74 / $360.74
| Professional | | $360.74 | $360.74 | $360.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,032.19 / $1,032.19 / $1,754.72
| Facility | | $1,032.19 | $1,032.19 | $1,754.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |