- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.07 / $237.07 / $237.07
| Facility | | $237.07 | $237.07 | $237.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.07 / $318.75 / $475.00
| Professional | | $237.07 | $318.75 | $475.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $244.24 / $504.76 / $602.62
| Facility | | $244.24 | $504.76 | $602.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $425.00
| Facility | | $318.75 | $318.75 | $425.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $79.73
| Professional | | $30.00 | $30.00 | $79.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.39 / $491.92 / $727.72
| Facility | | $346.39 | $491.92 | $727.72 |