- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.52 / $245.52 / $1,997.70
| Facility | | $245.52 | $245.52 | $1,997.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.52 / $245.52 / $271.77
| Professional | | $245.52 | $245.52 | $271.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $825.89 / $825.89 / $1,101.19
| Facility | | $825.89 | $825.89 | $1,101.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.00 / $265.74 / $567.46
| Professional | | $245.00 | $265.74 | $567.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.33 / $271.77 / $445.13
| Facility | | $236.33 | $271.77 | $445.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $55.00
| Professional | | $55.00 | $55.00 | $55.00 |