- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.66 / $292.66 / $307.12
| Facility | | $292.66 | $292.66 | $307.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.66 / $292.66 / $329.99
| Professional | | $292.66 | $292.66 | $329.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.00 / $804.00 / $1,322.00
| Professional | | $804.00 | $804.00 | $1,322.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.51 / $460.51 / $940.35
| Professional | | $460.51 | $460.51 | $940.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.75 / $672.85 / $1,034.80
| Professional | | $288.75 | $672.85 | $1,034.80 |