- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $519.15 / $578.48 / $3,517.16
| Facility | | $519.15 | $578.48 | $3,517.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.48 / $578.48 / $578.48
| Professional | | $578.48 | $578.48 | $578.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.64 / $778.72 / $1,023.46
| Professional | | $741.64 | $778.72 | $1,023.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $578.48 / $741.64 / $889.97
| Facility | | $578.48 | $741.64 | $889.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.49 / $407.90 / $675.34
| Professional | | $311.49 | $407.90 | $675.34 |