- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $751.55 / $751.56 / $2,061.67
| Facility | | $751.55 | $751.56 | $2,061.67 |
- 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
- $1,129.85 / $2,199.21 / $3,664.53
| Facility | | $1,129.85 | $2,199.21 | $3,664.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.77 / $477.77 / $477.77
| Professional | | $477.77 | $477.77 | $477.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $751.56 / $826.72 / $1,277.65
| Facility | | $751.56 | $826.72 | $1,277.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |