- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.28 / $575.28 / $575.28
| Facility | | $575.28 | $575.28 | $575.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.28 / $575.28 / $673.70
| Professional | | $575.28 | $575.28 | $673.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.54 / $810.05 / $810.05
| Professional | | $688.54 | $810.05 | $810.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.44 / $143.44 / $143.44
| Facility | | $143.44 | $143.44 | $143.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $409.64 / $409.64 / $409.64
| Professional | | $409.64 | $409.64 | $409.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,107.00 / $3,107.00 / $3,107.00
| Professional | | $3,107.00 | $3,107.00 | $3,107.00 |