- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $325.81 / $325.81 / $325.81
| Facility | | $325.81 | $325.81 | $325.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.11 / $325.81 / $602.67
| Professional | | $295.11 | $325.81 | $602.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.40 / $675.40 / $735.28
| Professional | | $675.40 | $675.40 | $735.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $325.81 / $325.81 / $325.81
| Facility | | $325.81 | $325.81 | $325.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.02 / $325.81 / $417.85
| Professional | | $318.02 | $325.81 | $417.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $2,062.33 / $2,062.33
| Professional | | $30.00 | $2,062.33 | $2,062.33 |