- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $758.58
| Facility | | $426.58 | $426.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $426.58 / $478.63
| Professional | | $251.19 | $426.58 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $389.05 / $1,905.46
| Facility | | $64.57 | $389.05 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Professional | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Facility | | $977.24 | $977.24 | $977.24 |