- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $738.00 / $900.00
| Facility | | $318.75 | $738.00 | $900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.10 / $318.75 / $425.00
| Professional | | $266.10 | $318.75 | $425.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.00 / $706.00 / $1,000.00
| Facility | | $510.00 | $706.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,012.87 / $1,012.87 / $1,012.87
| Facility | | $1,012.87 | $1,012.87 | $1,012.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.09 / $1,033.09 / $1,033.09
| Professional | | $1,033.09 | $1,033.09 | $1,033.09 |