- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.49 / $1,453.92 / $1,612.82
| Facility | | $794.49 | $1,453.92 | $1,612.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.65 / $1,453.92 / $1,612.82
| Professional | | $627.65 | $1,453.92 | $1,612.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.49 / $794.49 / $794.49
| Facility | | $794.49 | $794.49 | $794.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.49 / $794.49 / $794.49
| Professional | | $794.49 | $794.49 | $794.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Professional | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $333.69 / $476.69 / $1,350.63
| Professional | | $333.69 | $476.69 | $1,350.63 |