- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.78 / $213.56 / $213.56
| Facility | | $137.78 | $213.56 | $213.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.78 / $197.48 / $229.63
| Professional | | $137.78 | $197.48 | $229.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.00 / $494.00 / $1,160.90
| Professional | | $494.00 | $494.00 | $1,160.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.21 / $1,672.15 / $1,672.15
| Facility | | $537.21 | $1,672.15 | $1,672.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,750.16 / $1,750.16 / $2,658.53
| Professional | | $1,750.16 | $1,750.16 | $2,658.53 |