- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $288.40
| Facility | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $288.40
| Professional | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,311.31 / $7,413.10
| Facility | | $1,445.44 | $3,311.31 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $2,089.30 / $3,981.07
| Facility | | $288.40 | $2,089.30 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,884.03 / $5,754.40
| Facility | | $1,584.89 | $2,884.03 | $5,754.40 |