- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $636.88 / $721.80 / $926.38
| Facility | | $636.88 | $721.80 | $926.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.38 / $926.38 / $926.38
| Professional | | $926.38 | $926.38 | $926.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.11 / $808.36 / $964.98
| Professional | | $687.11 | $808.36 | $964.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.98 / $926.38 / $1,157.97
| Professional | | $771.98 | $926.38 | $1,157.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.23 / $926.38 / $1,157.97
| Professional | | $324.23 | $926.38 | $1,157.97 |