- 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
- $425.84 / $548.01 / $1,064.42
| Professional | | $425.84 | $548.01 | $1,064.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $593.60 / $740.17 / $1,062.61
| Facility | | $593.60 | $740.17 | $1,062.61 |