- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $568.00 / $1,826.00 / $2,448.00
| Facility | | $568.00 | $1,826.00 | $2,448.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $318.75 / $475.00
| Professional | | $250.00 | $318.75 | $475.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.01 / $630.00 / $1,064.10
| Facility | | $190.01 | $630.00 | $1,064.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.54 / $1,471.54 / $1,471.54
| Professional | | $1,471.54 | $1,471.54 | $1,471.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.53 / $432.55 / $859.16
| Facility | | $416.53 | $432.55 | $859.16 |