- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $475.00 / $1,645.44 / $3,673.00
| Facility | | $475.00 | $1,645.44 | $3,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $475.00
| Professional | | $318.75 | $318.75 | $475.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $561.00 / $686.40 / $728.00
| Facility | | $561.00 | $686.40 | $728.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $433.75 / $554.01 / $1,079.63
| Professional | | $433.75 | $554.01 | $1,079.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $378.22 / $471.61 / $677.06
| Facility | | $378.22 | $471.61 | $677.06 |