- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $737.82 / $737.82 / $737.82
| Facility | | $737.82 | $737.82 | $737.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.00 / $825.95 / $922.28
| Professional | | $617.00 | $825.95 | $922.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.82 / $470.82 / $691.19
| Professional | | $470.82 | $470.82 | $691.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.94 / $311.52 / $737.82
| Facility | | $245.94 | $311.52 | $737.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.28 / $540.87 / $819.80
| Professional | | $232.28 | $540.87 | $819.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.16 / $418.10 / $696.83
| Professional | | $172.16 | $418.10 | $696.83 |