- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.94 / $258.94 / $258.94
| Facility | | $258.94 | $258.94 | $258.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.46 / $198.70 / $258.94
| Professional | | $165.46 | $198.70 | $258.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $401.27 / $401.27 / $401.27
| Professional | | $401.27 | $401.27 | $401.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.97 / $228.51 / $446.35
| Facility | | $158.97 | $228.51 | $446.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.00 / $1,274.00 / $1,274.00
| Professional | | $1,274.00 | $1,274.00 | $1,274.00 |