- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.80 / $324.47 / $324.47
| Facility | | $263.80 | $324.47 | $324.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.82 / $263.80 / $324.47
| Professional | | $217.82 | $263.80 | $324.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.28 / $295.60 / $414.00
| Professional | | $235.28 | $295.60 | $414.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.10 / $287.10 / $287.10
| Professional | | $287.10 | $287.10 | $287.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.21 / $340.69 / $741.28
| Facility | | $239.21 | $340.69 | $741.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.46 / $1,733.46 / $1,733.46
| Professional | | $1,733.46 | $1,733.46 | $1,733.46 |