- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.72 / $151.36 / $151.36
| Facility | | $97.72 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $151.36 / $229.09
| Professional | | $104.71 | $151.36 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $338.84 / $338.84
| Professional | | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,348.96
| Professional | | $1,258.93 | $1,258.93 | $1,348.96 |