- 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
- $632.78 / $691.66 / $1,434.25
| Professional | | $632.78 | $691.66 | $1,434.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $283.60 / $353.62 / $507.67
| Facility | | $283.60 | $353.62 | $507.67 |