- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $517.29 / $517.29 / $517.29
| Facility | | $517.29 | $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
- Professional
- Modifier
- Low / Median / High Price
- $180.00 / $400.00 / $400.00
| Professional | | $180.00 | $400.00 | $400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.59 / $298.41 / $451.85
| Facility | | $117.59 | $298.41 | $451.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $517.29 / $543.16 / $1,105.04
| Facility | | $517.29 | $543.16 | $1,105.04 |