- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $541.41 / $855.25 / $1,404.29
| Facility | | $541.41 | $855.25 | $1,404.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.25 / $855.25 / $855.25
| Professional | | $855.25 | $855.25 | $855.25 |
- 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
- $440.66 / $440.66 / $440.66
| Professional | | $440.66 | $440.66 | $440.66 |
- 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 |