- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.35 / $307.35 / $307.35
| Facility | | $307.35 | $307.35 | $307.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.33 / $290.33 / $307.35
| Professional | | $290.33 | $290.33 | $307.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.98 / $467.00 / $478.62
| Professional | | $394.98 | $467.00 | $478.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.50 / $489.35 / $615.32
| Professional | | $484.50 | $489.35 | $615.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.96 / $307.35 / $1,945.90
| Facility | | $194.96 | $307.35 | $1,945.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.30 / $206.76 / $336.60
| Professional | | $168.30 | $206.76 | $336.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.16 / $186.23 / $336.60
| Professional | | $124.16 | $186.23 | $336.60 |