- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $282.00 / $1,477.68 / $1,937.34
| Facility | | $282.00 | $1,477.68 | $1,937.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.00 / $519.54 / $589.76
| Professional | | $282.00 | $519.54 | $589.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $720.25 / $720.25 / $720.25
| Facility | | $720.25 | $720.25 | $720.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.45 / $109.45 / $136.81
| Professional | | $109.45 | $109.45 | $136.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,196.16 / $1,630.39 / $2,375.94
| Facility | | $1,196.16 | $1,630.39 | $2,375.94 |