- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.71 / $164.71 / $164.71
| Facility | | $164.71 | $164.71 | $164.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.10 / $164.71 / $224.00
| Professional | | $134.10 | $164.71 | $224.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.66 / $562.82 / $609.47
| Professional | | $511.66 | $562.82 | $609.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.79 / $271.76 / $355.84
| Facility | | $175.79 | $271.76 | $355.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.36 / $1,066.36 / $1,066.36
| Professional | | $1,066.36 | $1,066.36 | $1,066.36 |