- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $314.18 / $1,086.86 / $1,562.72
| Facility | | $314.18 | $1,086.86 | $1,562.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.18 / $314.18 / $348.57
| Professional | | $314.18 | $314.18 | $348.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $604.96 / $1,103.00 / $1,821.16
| Facility | | $604.96 | $1,103.00 | $1,821.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.02 / $52.02 / $52.02
| Professional | | $52.02 | $52.02 | $52.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $314.18 / $530.96 / $1,005.08
| Facility | | $314.18 | $530.96 | $1,005.08 |