- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $264.25 / $273.75 / $283.70
| Facility | | $264.25 | $273.75 | $283.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.49 / $283.70 / $304.62
| Professional | | $247.49 | $283.70 | $304.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.50 / $1,769.50 / $3,415.14
| Facility | | $1,769.50 | $1,769.50 | $3,415.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.22 / $420.00 / $562.78
| Professional | | $314.22 | $420.00 | $562.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.77 / $281.77 / $287.20
| Professional | | $281.77 | $281.77 | $287.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.00 / $300.00 / $300.00
| Professional | | $267.00 | $300.00 | $300.00 |