- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.03 / $249.60 / $249.60
| Facility | | $161.03 | $249.60 | $249.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.03 / $249.60 / $285.02
| Professional | | $161.03 | $249.60 | $285.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.00 / $317.00 / $744.95
| Professional | | $317.00 | $317.00 | $744.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $552.69 / $1,720.72 / $1,720.72
| Facility | | $552.69 | $1,720.72 | $1,720.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.62 / $1,905.62 / $2,735.55
| Professional | | $1,905.62 | $1,905.62 | $2,735.55 |