- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $345.13 / $403.31 / $618.69
| Facility | | $345.13 | $403.31 | $618.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.34 / $362.00 / $474.44
| Professional | | $251.34 | $362.00 | $474.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.61 / $602.61 / $602.61
| Professional | | $602.61 | $602.61 | $602.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $65.00 / $70.00
| Professional | | $50.00 | $65.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $378.06 / $378.06 / $378.06
| Facility | | $378.06 | $378.06 | $378.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.53 / $602.61 / $602.61
| Professional | | $235.53 | $602.61 | $602.61 |