- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $384.42 / $384.42 / $403.52
| Facility | | $384.42 | $384.42 | $403.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.42 / $384.42 / $435.43
| Professional | | $384.42 | $384.42 | $435.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.00 / $1,062.00 / $1,744.00
| Professional | | $1,062.00 | $1,062.00 | $1,744.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $611.21 / $611.21 / $1,190.51
| Professional | | $611.21 | $611.21 | $1,190.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.59 / $794.84 / $1,388.01
| Professional | | $368.59 | $794.84 | $1,388.01 |