- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.56 / $1,140.00 / $2,825.00
| Facility | | $287.56 | $1,140.00 | $2,825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.56 / $287.56 / $287.56
| Professional | | $287.56 | $287.56 | $287.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.77 / $501.77 / $501.77
| Facility | | $501.77 | $501.77 | $501.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $506.37 / $506.37 / $506.37
| Facility | | $506.37 | $506.37 | $506.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.00 / $870.00 / $3,779.00
| Facility | | $455.00 | $870.00 | $3,779.00 |