- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.59 / $234.97 / $234.97
| Facility | | $151.59 | $234.97 | $234.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.59 / $234.97 / $252.66
| Professional | | $151.59 | $234.97 | $252.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.00 / $567.00 / $1,332.45
| Professional | | $567.00 | $567.00 | $1,332.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $487.38 / $1,517.75 / $1,517.75
| Facility | | $487.38 | $1,517.75 | $1,517.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.46 / $1,733.46 / $2,412.67
| Professional | | $1,733.46 | $1,733.46 | $2,412.67 |