- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,479.11
| Facility | | $1,288.25 | $1,288.25 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,479.11
| Professional | | $1,230.27 | $1,230.27 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $54.95 / $54.95
| Professional | | $54.95 | $54.95 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $25.12 / $50.12
| Professional | | $21.38 | $25.12 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,047.13 / $1,412.54
| Professional | | $125.89 | $1,047.13 | $1,412.54 |