- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.74 / $662.00 / $1,002.00
| Facility | | $269.74 | $662.00 | $1,002.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.00 / $269.74 / $300.00
| Professional | | $171.00 | $269.74 | $300.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.10 / $141.80 / $400.00
| Facility | | $83.10 | $141.80 | $400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.63 / $302.63 / $320.44
| Facility | | $302.63 | $302.63 | $320.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.93 / $200.65 / $318.07
| Professional | | $155.93 | $200.65 | $318.07 |