- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.02 / $206.02 / $206.02
| Facility | | $206.02 | $206.02 | $206.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.02 / $206.02 / $272.27
| Professional | | $206.02 | $206.02 | $272.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $285.27 / $567.20 / $735.26
| Facility | | $285.27 | $567.20 | $735.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.10 / $307.22 / $526.66
| Professional | | $273.10 | $307.22 | $526.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.38 / $373.38 / $514.32
| Facility | | $373.38 | $373.38 | $514.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.37 / $317.37 / $2,078.23
| Professional | | $317.37 | $317.37 | $2,078.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.60 / $280.72 / $349.34
| Professional | | $209.60 | $280.72 | $349.34 |