- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.78 / $1,387.89 / $3,439.80
| Facility | | $507.78 | $1,387.89 | $3,439.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.78 / $507.78 / $744.10
| Professional | | $507.78 | $507.78 | $744.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $775.73 / $1,599.69 / $2,960.14
| Facility | | $775.73 | $1,599.69 | $2,960.14 |
- 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
- $489.34 / $489.34 / $489.34
| Professional | | $489.34 | $489.34 | $489.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.64 / $1,277.49 / $1,859.53
| Facility | | $503.64 | $1,277.49 | $1,859.53 |