- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $352.00 / $352.00 / $352.00
| Facility | | $352.00 | $352.00 | $352.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.64 / $252.64 / $252.64
| Professional | | $252.64 | $252.64 | $252.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $77.02 / $79.40 / $313.77
| Facility | | $77.02 | $79.40 | $313.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.68 / $421.68 / $421.68
| Professional | | $421.68 | $421.68 | $421.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.64 / $756.54 / $1,038.05
| Facility | | $252.64 | $756.54 | $1,038.05 |