- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.25 / $705.00 / $1,443.00
| Facility | | $224.25 | $705.00 | $1,443.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $318.75 / $318.75
| Professional | | $250.00 | $318.75 | $318.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.61 / $366.42 / $685.04
| Facility | | $165.61 | $366.42 | $685.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.54 / $1,471.54 / $1,471.54
| Professional | | $1,471.54 | $1,471.54 | $1,471.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $368.47 / $563.32 / $1,065.35
| Facility | | $368.47 | $563.32 | $1,065.35 |