- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $413.84 / $517.29 / $517.29
| Facility | | $413.84 | $517.29 | $517.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.29 / $517.29 / $550.00
| Professional | | $517.29 | $517.29 | $550.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.78 / $174.55 / $338.39
| Facility | | $98.78 | $174.55 | $338.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.22 / $477.36 / $477.36
| Professional | | $428.22 | $477.36 | $477.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.67 / $349.33 / $542.22
| Facility | | $122.67 | $349.33 | $542.22 |