- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $751.56 / $751.56 / $1,163.50
| Facility | | $751.56 | $751.56 | $1,163.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.56 / $751.56 / $751.56
| Professional | | $751.56 | $751.56 | $751.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $963.57 / $1,152.99 / $1,457.71
| Facility | | $963.57 | $1,152.99 | $1,457.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.77 / $477.77 / $477.77
| Professional | | $477.77 | $477.77 | $477.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $345.40
| Professional | | $100.00 | $200.00 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |