- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Facility | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,238.72 / $2,238.72
| Professional | | $1,995.26 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $407.38 / $645.65
| Facility | | $223.87 | $407.38 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $50.12
| Professional | | $32.36 | $33.11 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $478.63 / $831.76
| Facility | | $302.00 | $478.63 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $39.81 / $60.26
| Professional | | $34.67 | $39.81 | $60.26 |