- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,376.50 / $3,132.00 / $7,506.50
| Facility | | $1,376.50 | $3,132.00 | $7,506.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.00 / $1,686.00 / $4,573.00
| Professional | | $606.00 | $1,686.00 | $4,573.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $565.00 / $750.00 / $832.00
| Facility | | $565.00 | $750.00 | $832.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.01 / $158.51 / $165.01
| Professional | | $149.01 | $158.51 | $165.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,648.00 / $14,648.00 / $14,648.00
| Facility | | $14,648.00 | $14,648.00 | $14,648.00 |