- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.52 / $273.52 / $273.52
| Facility | | $273.52 | $273.52 | $273.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.52 / $273.52 / $367.31
| Professional | | $273.52 | $273.52 | $367.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.60 / $787.36 / $883.59
| Professional | | $649.60 | $787.36 | $883.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.93 / $453.42 / $570.14
| Professional | | $448.93 | $453.42 | $570.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.52 / $465.00 / $1,856.06
| Facility | | $273.52 | $465.00 | $1,856.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.12 / $390.75 / $664.28
| Professional | | $164.12 | $390.75 | $664.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.12 / $390.75 / $566.59
| Professional | | $164.12 | $390.75 | $566.59 |